Every finding on record at Kentmere Rehabilitation and Healthcare Center

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to:1. Provide supervision to prevent a fall for 1 (Resident #110) of 3 residents reviewed for falls. While providing care to Resident #110 on [DATE], Certified Nurse Aide (CNA) #16 turned her back to the resident and the resident jerked and fell to the floor. Initially, the resident was transferred to a hospital and received four sutures for a skin tear to the left side of their forehead. Two days later, on the morning of [DATE], CNA #16 noted swelling to resident #110's left hip and thigh and the resident had limited range of motion (ROM) to the left leg. The resident's physician was notified, and an x-ray was obtained, which revealed a fracture and displacement to the resident's left femur (hip area). After consultation with the resident's Responsible Party (RP) regarding the resident not being a candidate for hip surgery, the RP chose not to send the resident to the hospital and initiated comfort care measures and pain management at the facility. Resident #110 expired in the facility on [DATE].2. Identify and remove an accident hazard from 1 (Resident #62's room) of 25 rooms on the 300 Unit, which was the dementia unit. Specifically, an observation on [DATE] revealed broken glass in a picture frame in Resident #62's restroom. Interviews revealed that a staff member observed the broken picture frame on [DATE]; however, no action was taken to remove the broken glass. Findings included:A facility policy titled, Accidents and Supervision, dated [DATE], indicated, Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. l. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The policy also revealed, 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 1. Resident #110's admission Record indicated the facility admitted the resident on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, muscle weakness (generalized), cognitive communication deficit, unilateral primary osteoarthritis of the right knee, the need for assistance with personal care, and repeated falls.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting and personal hygiene, bathing, dressing, rolling left to right in bed, moving from sitting to lying position, moving from lying to sitting on the side of the bed, and chair-to-bed transfers. Resident #110's Care Plan Report included a focus area initiated [DATE], that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to Alzheimer's disease and impaired balance. Interventions (revised [DATE]) directed staff that the resident was dependent on at least one staff member to provide a bath or shower; dependent on staff to turn from side to side, sit up and lie down, and reposition in bed; dependent on staff for incontinence care, changing their brief, and clothing management; and dependent on two staff to move between surfaces.A facility FRI [Facility Reported Incident] 5 day Follow Up Report, dated [DATE], indicated that on [DATE], during morning care, the resident fell when a CNA (CNA #16) turned to obtain a washcloth from the cart. Per the FRI, CNA #16 reported that as soon as they turned their back, Resident #110 jerked off the bed. It happened so fast. The report revealed the resident was transferred to the hospital for a laceration to the forehead and a computed tomography (CT) scan of the head and cervical spine and returned with stitches to the forehead. According to the FRI report, on [DATE] at 8:30 AM, staff noted that Resident #110 had left hip/thigh swelling. The report revealed staff notified the physician and an x-ray was ordered of the bilateral hips, left tibia and fibula. Per the report, the x-ray revealed that Resident #110 had a fracture involving the proximal left femur with displacement. The facility's report also revealed that a provider discussed the hip x-ray results and treatment with the resident's power of attorney (POA) and due to being bed/wheelchair bound and having end stage dementia, the family chose comfort care/pain management with no hospitalization.Resident #110's [DATE] Medication Administration Record [MAR] revealed staff documented that the resident had no pain on [DATE] through [DATE]. The MAR revealed staff documented that the resident had a pain level of 2 (with 0 being no pain, and 10 being the worst pain imaginable) on [DATE]. Per the MAR, acetaminophen 500 milligrams (mg), two tablets three times per day, was started on [DATE] at 1:00 PM. The MAR revealed the resident had a pain level of 6 on [DATE], a pain level of 5 on [DATE], and a pain level of 4 on [DATE]. Resident #110's August MAR revealed staff documented that the resident had no pain.Resident #110's Radiology Results Report dated [DATE] revealed bilateral hip x-rays indicated the resident had a recent facture involving the proximal left femur with displacement. CNA #16's personnel file revealed an Employee Disciplinary Notice dated [DATE], that indicated the employee was given a written warning related a fall incident on [DATE]. The notice indicated that CNA #16 turned to get a washcloth off a cart, which was located away from the resident, when the fall occurred. The Employee Disciplinary Notice revealed that on [DATE], the resident was noted with left hip/thigh swelling, and an x-ray was ordered. On [DATE], the results were received, which indicated a fracture of the left femur. The notice concluded that Due to the negligent practice during daily care the resident sustained an injury, and that any further actions of that type would result in progressive discipline up to and including termination. A Memorandum dated [DATE] to CNA #16 revealed the director met with the CNA concerning resident safety and protocols when providing bed baths, showers, perineal care, or other tasks. Per the Memorandum, the resident's bed could be raised to a height that was ergonomically correct for the task to prevent staff injury. However, staff could not leave the resident unattended at any time when the bed was raised. According to the Memorandum, leaving a bed at a raised height put the resident at risk of falling out of bed and getting injured. The Memorandum revealed, To prevent injury, staff MUST lower the bed to its lowest position when leaving the bedside for any reason, regardless of how short a distance away from the resident or length of time. Additionally, it is best practice to gather necessary supplies and linen needed to provide the required care. During a telephone interview on [DATE] at 9:49 PM, Resident #110's RP stated that Resident #110 had been declining before the fall on [DATE]. The RP stated they were in the facility when the resident's physician saw the resident post fall. The RP stated that the facility obtained an x-ray, which revealed a broken hip. According to the RP, the physician spoke with them, and since the resident was not a good candidate for surgery due to their weight and decline, they chose in-house hospice care. The RP stated that the resident was not the same after the fall. The RP stated they felt that nursing staff should have been providing care in pairs because of the resident's movement. Telephone interviews were attempted with CNA #16 on [DATE] at 8:39 AM, at 1:30 PM, at 2:34 PM, and at 2:35 PM. A voicemail was able to be left at 2:34 PM on [DATE]; however, no return call was received prior to exiting the survey.During an interview on [DATE] at 2:36 PM, the Executive Director (ED) stated that CNA #16 was on vacation.During a telephone interview on [DATE] at 3:18 PM, RN #18 stated CNA #16 told her the resident fell out of bed and she assessed the resident after the fall on [DATE]. She stated CNA #16 told her that she had turned away from the resident and the resident fell out of bed. She stated the resident had a cut on their head and was sent to the hospital. She stated that the resident indicated no pain in their hips or thighs during assessment. During an interview on [DATE] at 1:49 PM, Licensed Practical Nurse (LPN) #23 stated Resident #110 had been on the unit for a long time and was wheelchair bound. He stated the resident had jerking movements when in the bed while care was being provided, as well as in their wheelchair. He stated he was working on [DATE] when the resident's x-ray results came back and showed a fracture of the resident's left extremity. He stated the family was notified, and they chose to provide comfort care for the resident and not transfer the resident to the hospital. He stated he spoke with the physician, who ordered extra strength Tylenol for pain. According to LPN #23, Resident #110 had been declining and was not their usual self before the fall.During an interview on [DATE] at 1:25 PM, CNA #1 stated that she was not on shift when the fall occurred on [DATE]. She stated Resident #110 would throw themselves to one side of the bed and jerked their body around. She stated that when providing care for residents who jerked, she stayed at the side of the bed, so they did not fall.During an interview on [DATE] at 2:15 PM, LPN #22 stated Resident #110 was nonverbal, dependent on staff for care, and used a Hoyer lift for transfers. She stated the resident required two people for transfers but not for ADL care. LPN #2 stated that the resident had jerking movement when in bed and in their wheelchair. She stated the resident had been declining before the fall and had a decrease in appetite. During an interview on [DATE] at 12:19 PM, the Medical Director (MD) stated Resident #110 had been in the facility since 2019 and did not have a history of frequent falls or unsafe transfers. She stated the resident had a fall on [DATE] that resulted in a fracture. She stated the resident was sent to the hospital after the fall, and she saw the resident when the resident returned to the facility. The MD stated the resident was sitting in their wheelchair for the examination and had swelling and frowned when range of motion of the lower left extremity was assessed. She stated an x-ray was ordered and a fracture was found. She stated the resident had end stage of dementia, was not doing well, and was not a candidate for hip surgery. She stated that the resident's RP elected to place the resident on comfort care. During an interview on [DATE] at 3:28 PM, the Director of Nursing (DON) stated CNA #16 notified her that Resident #110 had jerking movements, which were normal for the resident, that caused the resident to fall out of bed. She stated CNA #16 told her that she had turned around to grab an item, and when she turned back around, the resident had fallen out of bed. Per the DON, the facility concluded negligence because the bed should be lowered to the floor and fall mats replaced at the bedside if staff had to leave the resident during care. The DON stated facility CNAs were trained to gather all their supplies and anticipate the needs of the resident before providing care to prevent these incidents. She stated the fall that resulted in the disciplinary action for CNA #16 could have been prevented. The DON stated that initially, Resident #110 indicated no pain to their lower extremities or hips and was transferred to the hospital, where they scanned the resident's head and neck and found no injury. She stated that on [DATE], while CNA #16 was providing care to the resident, she noticed swelling to their thigh and notified the nurse. Per the DON, the physician came in to assess the resident and after the fracture was found, Resident #110's RP opted for comfort care. She stated Resident #110 had osteoarthritis, which could affect the strength of their bones. She stated that the resident had also experienced a decline before the fall in [DATE]. During a follow-up interview on [DATE] at 11:22 AM, the DON stated she felt CNA #16 made a mistake and was not careful with Resident #110 on [DATE], but there was nothing intentional about her actions. She stated she had no prior knowledge of the resident's jerking movements until she investigated the fall and spoke with CNA #16. She stated she had not witnessed those movements from the resident.During an interview on [DATE] at 3:08 PM, the ED stated that Resident #110 went to the hospital after the fall. She stated when staff noticed the resident was grimacing upon return from the hospital, a hip x-ray was completed, which indicated a fracture. She stated the resident had no previous falls.2. An admission Record indicated the facility admitted Resident #62 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia with agitation, anxiety disorder, and repeated falls.A quarterly Minimum Data Set, with an Assessment Reference Date (ARD) of [DATE], revealed Resident #62 had a Brief Mental Status Score (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was independent with ambulation and required supervision or touching assistance during toileting transfers. During an observation on [DATE] at 4:58 PM of the restroom in Resident #62's room, a piece of artwork approximately 18 inches by 24 inches was seen lying on a table inside the restroom door. The observation revealed another piece of artwork on top of it, measuring approximately 12 inches by 12 inches. The glass covering the 18-inch by 24-inch picture was shattered, and some glass was loose. All the broken glass was contained in the frame, and the loose shards were underneath the 12-inch by 12-inch picture. No broken glass was seen on the floor of the resident's restroom, and Resident #62 was not in their room.During an interview on [DATE] at 6:20 PM, Licensed Practical Nurse (LPN) #2 stated that the glass was unsafe and someone could hurt themself. He stated Resident #62 used their restroom and there were wandering residents on the unit that went into other residents' rooms. He stated the resident did not have any physical behaviors that would have caused the broken glass, but they may have knocked it off the wall trying to stabilize themself. He stated maintenance should have been notified, and the picture removed from the restroom. He stated nothing was shared with him during shift report about the broken glass. During an interview on [DATE] at 3:15 PM, Registered Nurse (RN) #7 stated she worked on the unit where Resident #62 resided on [DATE] and did not recall anything memorable happening in the resident's room. She stated there were no loud crashes or reports of broken glass. RN #7 stated that the nurse did not normally go into the resident's room, and the resident was able to communicate their needs to the staff. She stated the resident was able to use the restroom on their own, and the certified nurse aides (CNAs) waited outside the door if the resident needed assistance. Per the RN, if the resident found a broken picture in their restroom, they would have told the staff or brought it to them. She stated that broken glass should be cleaned up immediately to prevent injury to the residents. She stated there were residents that wandered the unit that could get hurt. During an interview on [DATE] at 12:17 PM, Housekeeper (HK) #26 stated that the housekeeper who normally covered the unit where Resident #62 resided was on vacation, and she had been covering the 300 Unit for the past two weeks. HK #26 stated that she helped move Resident #62 into their room in [DATE], and the glass in the picture was intact. She stated she slid the two pictures between the nightstand and the wall in the resident's restroom to minimize the chances of them falling and breaking. HK #26 stated that she saw the broken glass in Resident #62's room on Monday morning ([DATE]) when she was cleaning the restroom. However, she stated she did not tell the nursing staff about the glass and forgot to return to the room to clean it up. She stated that broken glass on the units was dangerous because one of the residents may get cut.During an interview on [DATE] at 1:25 PM, CNA #1 stated she worked with Resident #62 on [DATE], and she had worked with them that day, [DATE]. She stated she knew of no incidents in the resident's room and had not seen any broken glass. She stated she assisted the resident to the restroom on [DATE]; however, she remained outside of the restroom door until the resident was finished because the resident did not like people in the restroom with them. CNA #1 stated that she recalled seeing pictures on the nightstand in the restroom but was unsure when she first saw them there. She stated there were residents on the unit who wandered into other residents' rooms, but they usually avoided the rooms in the common area close to the nurses' station. She stated that if she saw broken glass in a resident's room, she would clean it up because it could be dangerous if touched. She also stated that she encouraged family members to not bring glass into the unit. During an interview on [DATE] at 2:11 PM, LPN #3 stated she was working on the unit where Resident #62 resided on the day shift of [DATE] but stated that she did not enter the resident's restroom. She stated Resident #62 was very steady on their feet and was able to take themself to the restroom but asked for staff assistance. She stated that broken glass was hazardous to the residents on the unit.During an interview on [DATE] at 2:15 PM, the Director of Maintenance (DOM) stated that prior to the evening of [DATE], he had not received a report of broken glass in Resident #62's restroom. He stated the broken glass should have been removed. During an interview on [DATE] at 8:07 AM, the Director of Nursing (DON) stated if the staff saw a broken picture frame in a resident's room, they should call maintenance to look at the broken item and call housekeeping to clean up the glass. She stated there were four residents that wandered on the 300 Unit; however, there had been no injuries caused by potentially broken glass. She stated LPN #2 notified her of the broken glass on Tuesday evening ([DATE]). She stated she spoke with a couple of staff about the frame, and no one knew about the broken glass. During an interview on [DATE] at 9:14 AM, the Executive Director (ED) stated if broken glass was found in resident rooms, housekeeping should be notified to clean it up or the staff member who discovered it should clean it up. She stated she was unaware that HK #26 knew about the broken glass on Monday, [DATE].

Based on observation, interview, and facility policy review, the facility failed to ensure foods items stored in the walk-in refrigerator and freezer were covered, labeled and dated and expired food items were discarded. The facility further failed to ensure wash dishes as directed by the facility policy. Lastly, the facility failed to ensure hot foods were held on the tray line at a temperature of at least 135 degrees Fahrenheit. These deficient practices had the potential to affect residents who received food from the kitchen. Findings included:1. A policy titled, Food Receiving and Storage, revised 10/2017, indicated, Policy Statement Food shall be received and stored in a manner that complies with safe food handling practices. Per the policy, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).During a concurrent interview and observation of the walk-in refrigerator with the Dietary Director (DD) on 12/09/2025 at 4:15 PM, the following was noted: - One plastic bottle of horseradish sauce stored after opening did not have a label to record the date opened or the use by date (UBD). The DD stated the horseradish should have a label with the date opened and a UBD.- A plastic bottle of water identified by the DD as belonging to an employee was stored on a shelf. The DD stated employees' food should not be stored in the refrigeration with food for residents.- A 12-ounce plastic container of minced garlic was stored after opening without a label to include the date opened or a UBD.- A 12-ounce container of chocolate syrup was stored after opening without a label to include the date opened or UBD.- Six clear plastic bags of flour tortillas contained 14 tortillas per bag with a manufacturer best by date of 11/04/2025. The DD stated the flour tortillas should have been discarded by the manufacturer best by date.- A container of leftover cooked carrots was stored with no date of storage or UBD.- Three flats of fresh shelled unpasteurized eggs with 24 eggs per flat were stored with one flat stacked on top of the other. The top flat of eggs contained two eggs that were cracked, which exposed the white/yolk that spilled onto the remaining eggs on the top flat. The DD stated the flat with two cracked eggs should have been discarded.- A five-pound box of yellow cake mix was stored opened to air. The DD stated the box should be stored in a closed/sealed container.- A ten-pound box of fresh bell peppers included five bell peppers with dark soft spots and fuzzy hair-like growth, identified as mold by the DD. The DD stated the five bell peppers should be discarded.- Parsley wrapped in plastic wrap was stored without a date of storage or a UBD. The DD stated the parsley should have the date of storage and UBD.- Three stalks of celery stored in a plastic bag were brown, soft, and in a pool of brown-colored liquid. The DD stated the celery had signs of spoilage and should be discarded.- A 25-pound box of fresh tomatoes had 25 tomatoes that were soft/mushy with hair-like growth identified by the DD as mold. The DD stated the 25 tomatoes should be discarded. During a concurrent interview and observation of the freezer with the DD on 12/09/2025 at 4:44 PM, there was a plastic bag that contained 40 frozen omelets and was stored opened to air. The DD stated the bag of omelets was exposed to air, stored without being properly sealed, and should be sealed and dated with a UBD. During an interview on 12/09/2025 at 4:55 PM, the DD stated he expected all dietary staff to label/date foods when they were returned to the walk-in refrigerator. According to the DD, he and the cooks were responsible for monitoring the walk-in refrigerator and freezer for items properly stored. During an interview on 12/11/2025 at 12:55 PM, the Executive Director stated she expected dietary staff to date/label all items stored in refrigeration, monitor cold storage at least each shift to ensure all items were labeled/dated, and remove all expired foods. During an interview on 12/11/2025 at 2:15 PM, the Director of Nursing (DON) stated she expected dietary staff to label/date items with the open date and the date it expired before items were placed in refrigeration. The DON also stated she expected food to be stored covered. 2. A facility policy titled, Dishwashing Machine Use, revised 03/2012, indicated 2. Dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: 140 F [degrees Fahrenheit] for stationary rack, dual temperature machines, or multi-tank, conveyor, multi-temperature machines. 3. Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than, b. 180 F for all other machines. The policy specified, 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. During a concurrent interview and observation of the dish machine in use by Dietary Aide (DA) #10 on 12/09/2025 at 5:02 PM, revealed as DA #10 washed a tray of forks, knives, and spoons, the dish machine registered a wash temperature of 118 degrees F, and the final rinse temperature did not register but indicated Probe Error, Final Rinse. DA #10 stated he did not check the dish machine temperatures before or during the wash cycle. During an interview on 12/09/2025 at 5:10 PM, the Dietary Director (DD) stated the dish machine was a high-temperature machine, and the manufacturer wash cycle temperature should be at least 150 degrees F and the final rinse temperature should be at least 180 degrees F. During a follow-up interview on 12/11/2025 at 12:32 PM, the DD stated he was not aware of the Probe Error on the dish machine as DA #10 did not report any concerns to him regarding the dish machine, but that DA #10 should have reported the Probe Error message to him. The DD stated that he expected staff to check the wash/rinse cycle temperature while the dish machine was in use and report any concerns to him immediately. During an interview on 12/11/2025 at 12:55 PM, the Executive Director (ED) stated she expected dietary staff to monitor the water temperature of the dish machine with each use and report to the supervisor if water temperatures were too low. The ED stated that dietary staff should wash dishes per the facility policy/manufacturer instructions for wash/rinse cycle temperatures and if the temperatures were too low, dietary staff should wash dishes in the 3-compartment sink until the issue was resolved. During an interview on 12/11/2025 at 2:15 PM, the Director of Nursing stated she expected the dietary staff to wash/rinse dishes in the dish machine using water that was hot enough.3. A facility policy titled, Record of Food Temperatures, implemented 10/20/2024, indicated 2. Hot foods will be held at 135 degrees Fahrenheit or greater.During a concurrent interview and observation of lunch tray line on 12/11/2025 at 12:18 PM, the temperature of the pureed green beans was 111 degrees F and the mechanically chopped pork was 127 degrees F to 131 degrees F. [NAME] #11 stated hot foods should be held at a temperature of at least 135 degrees F or higher. [NAME] #11 stated a thermometer was typically kept in the hot holding unit for temperature monitoring, but that unit currently did not have a thermometer. During an interview on 12/11/2025 at 12:48 PM, the Dietary Director (DD) stated hot foods should be held at least 135 degrees F and the thermometer used to monitor the temperature of the hot holding unit was not inside the unit. The DD stated he last saw the thermometer inside the hot holding unit a few days prior. During an interview on 12/11/2025 at 12:55 PM, the Executive Director stated she expected hot foods to be held at the correct hot holding temperature. During an interview on 12/11/2025 at 2:15 PM, the Director of Nursing stated she expected hot foods to be kept hot throughout the tray line to make sure there was no opportunity for bacteria to grow.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency that involved 2 (Resident #11 and Resident #19) of 7 sampled residents reviewed for abuse. The facility further failed to ensure staff immediately reported an allegation of abuse to the Director of Nursing and/or Executive Director for 3 (Residents #18, #34, and #37) of 7 sampled residents reviewed for abuse. Findings included:A facility policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime, updated 10/2019, revealed, Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours.1. An admission Record revealed the facility admitted Resident #11 on 08/04/2021. According to the admission Record, the resident had a medical history that included diagnoses of neurocognitive disorder with Lewy bodies, dementia without behaviors, and mild cognitive impairment. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2025, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #11's progress note dated 07/17/2025 at 12:13 PM, indicated the resident became physically aggressive with another resident. Facility documentation indicated the facility notified the state survey agency of an incident that involved Resident #11 and Resident #19 on 07/17/2025 at 3:48 PM, four and a half hours after the incident occurred. During an interview on 12/11/2025 at 11:33 AM, the Director of Nursing (DON) stated the facility had two hours to report abuse to the state agency. During a follow-up interview on 12/11/2025 at 3:53 PM, the DON stated the incident that involved Resident #11 and Resident #19 was not submitted within two hours to the state survey agency and it should have been. 2. An admission Record revealed the facility admitted Resident #18 on 08/28/2024. According to the admission Record, the resident had a medical history to include a diagnosis of cognitive communication deficit. An annual Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 09/06/2025, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. An admission Record revealed the facility admitted Resident #37 on 09/22/2023. According to the admission Record, the resident had a medical history to include a diagnosis of dementia. An annual MDS, with an ARD of 09/29/2025, revealed Resident #37 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The facility incident summary report indicated on 05/08/2025 at 9:30 PM, Resident #18 touched the breast of Resident #37. Per the facility incident summary report, this incident was not reported to the state survey agency until 05/09/2025 at 2:25 PM. During an interview on 12/10/2025 at 2:56 PM, the Director of Nursing (DON) stated she was notified on 05/09/2025 of the resident-to-resident sexual abuse incident between Resident #18 and Resident #37 that occurred on 05/08/2025. The DON stated the incident was reported to the state agency on 05/09/2025. The DON stated she should have been notified on 05/08/2025 of the incident. The DON stated Licensed Practical Nurse (LPN) #20 did not follow the notification process for allegations of abuse and was no longer employed by the facility. During an interview on 12/11/2025 at 11:33 AM, the Executive Director (ED) stated she was not in the facility at the time of the resident-to-resident sexual abuse incident between Resident #18 and Resident #37 that occurred on 05/08/2025. The ED stated LPN #20 notified the DON the next day, 05/09/2025, about the incident of sexual abuse between Resident #18 and Resident #37 and said that she forgot to contact the DON to notify her of the incident when it occurred. The ED stated she was also notified by the DON on 05/09/2025, which was also the day the incident was reported to the state survey agency. The ED stated the incident should have been reported to the state agency on 05/08/2025 within two hours of the incident.3. An admission Record revealed the facility admitted Resident #34 on 10/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, traumatic brain injury, and asthma.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #34's Care Plan Report included a focus area that indicated the resident was at risk for complications related to asthma and COPD, with an intervention that directed staff to give medications as ordered (initiated 10/24/2024).The incident report form dated 10/07/2025, revealed the facility identified on 10/07/2025 at 1:09 PM that Resident #34 had bruising and swelling to their right pointer finger and knuckles. The report revealed the resident reported to the Director of Nursing (DON) and Assistant Director of Nursing that the injury resulted when Licensed Practical Nurse (LPN) #8 allegedly forced the inhaler out of the resident's hand after the resident refused to give it back to the nurse on 10/03/2025 at 9:30 PM. Per the incident report, the facility notified the state survey agency of the incident on 10/07/2025 at 5:35 PM.During an interview on 12/12/2025 at 9:50 AM, the DON acknowledged the incident that involved Resident #34 was not timely reported to the state survey agency.During an interview on 12/12/2025 at 3:29 PM, the Executive Director stated it was disappointing that staff did not timely report the allegation of abuse to their supervisor.

Based on interview, record review, document review, and facility policy review, the facility failed to interview all persons identified as involved or with knowledge of an occurrence for 2 (Resident #34 and Resident #93) of 7 sampled residents reviewed for abuse. Findings included:A facility policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime, updated 10/2019, indicated, Investigation *All alleged incidents involving abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, including injuries of unknown source, shall be reported to the NHA [nursing home administrator] or designee immediately. *The NHA or designee will investigate allegations and report to appropriate regulatory agencies. *All persons identified as involved in or with knowledge of the occurrence will be interviewed.1. An admission Record revealed the facility admitted Resident #34 on 10/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, traumatic brain injury, and asthma.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The facility investigation revealed the facility identified Resident #34 had a bruise and swelling to their finger on 10/07/2025. The investigation indicated that Resident #34 reported to the Director of Nursing (DON) that on 10/07/2025 at 3:30 PM, Licensed Practical Nurse (LPN) #8 caused the bruise by pulling Resident #34's inhaler out of their hand. The facility investigation included an interview with Resident #34, an interview with LPN #8, and statements from staff who worked with Resident #34. The facility investigation included information that a certified nurse aide reported that Resident #34 told a therapist that they had hit their hand. The facility investigation did not include statements from the therapist. During an interview on 12/11/2025 at 12:03 PM, the Speech Language Pathologist (SLP) stated he worked with Resident #34 on 10/03/2025 and 10/07/2025. The SLP stated he vaguely remembered Resident #34 mentioning having an incident with a staff member where the resident stated they tried to grab something but the staff member grabbed it from them.During an interview with the DON and Assistant DON on 12/12/2025 at 2:22 PM, the DON stated that she would expect any staff that worked with Resident #34 within 24 hours of the bruise being identified to be interviewed.During an interview on 12/12/2025 at 3:29 PM, the Executive Director stated she expected an abuse investigation to include statements from anyone who worked with the resident in the previous 72 hours to try to determine what happened as quickly as possible.2. An admission Record revealed the facility admitted Resident #93 on 08/11/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, osteoporosis, glaucoma, muscle weakness, and history of falling.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment.Resident #93's nurse's note written by Licensed Practical Nurse (LPN) #13 and dated 05/15/2025 at 5:35 PM, indicated the resident's index finger was bruised, swollen, and warm to the touch.The facility investigation revealed Resident #93's sustained a fracture of unknown origin. The facility investigation did not include statements from Registered Nurse #12 or LPN #13.During an interview with the Director of Nursing (DON) and Assistant DON on 12/12/2025 at 2:22 PM, the ADON stated the facility interviewed all staff that worked with Resident #93, but she should have gone back 24 hours from the time the bruise was identified and interviewed those staff members that worked with Resident #93. The ADON stated they did not have a statement from RN #12.During an interview on 12/12/2025 at 3:29 PM, the Executive Director stated whenever there was an injury of unknown origin, there was a 72-hour look-back period, and the facility should get statements from anyone who worked with the resident during that period

Based on observation and facility policy review, the facility failed to ensure they had an effective pest control program to address the infestation of rodents on 1 (3rd floor) of 4 floors in the facility. Findings included:A facility policy titled, Pest Control Program, revised 12/21/2024, indicated, Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Per the policy, Policy Explanation and Compliance Guidelines: 1. Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 2. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. 3. Facility will maintain a report system of issues that may arise between scheduled visits with the outside pest service and treat as indicated.During an observation on the 3rd floor on 12/09/2025 at 4:10 PM, there was a sticky trap with evidence of rodent droppings in the dining room by one of the windows opposite the entrance to the dining rom. There was evidence of rodent droppings behind the fish tank in the common room. Also noted was rodent droppings in room [ROOM NUMBER] behind the entry door. There was evidence of rodent droppings under a large dresser in the right corner of room [ROOM NUMBER]. There was evidence of rodent droppings under the large dresser that was tucked into a cubby as well as the back wall near the heating/cooling unit in room [ROOM NUMBER]. During an observation of the dining room on the 3rd floor on 12/13/2025 at 8:15 AM, a live mouse was seen under one of the tables.During an interview on 12/10/2025 at 1:25 PM, Certified Nurse Aide (CNA) #1 stated she had been employed by the facility since 2021. According to CNA #1, mice in the facility came out at night, especially in room [ROOM NUMBER].During an interview on 12/11/2025 at 1:53 PM, the Director of Maintenance (DOM) stated he had worked in the facility for the past two and a half years. The DOM stated residents and staff would report pest sightings and the pest control company would be notified. According to the DOM, sticky traps were placed around the perimeter of the facility to catch the mice. The DOM acknowledged he was very much aware of the various complaints about mice and other rodents in the facility. During an interview on 12/11/2025 at 3:00 PM, the Executive Director stated she was aware of the rodent issue in the facility and acknowledged it had been a problem for the past year. During an interview on 12/12/2025 at 10:02 AM, the Director of Nursing stated the facility had been addressing the pest control issue and recently changed pest control companies.

Based on interviews, record review, and review of the facility policy, the facility failed to ensure the narcotic count sheets on each medication cart for the oncoming nurse and off going nurse were documented prior to finishing the narcotic count to ensure accuracy of the narcotics for five of five medication carts reviewed of 40 sample residents. This failure had the potential for drug diversion. Findings include. Review of an undated facility's policy titled, Controlled Medication Storage and Accountability, revealed .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations . 1. Review of the third floor 300-medication cart narcotic sheet with Licensed Practical Nurse (LPN) 1 on 11/19/24 at 4:19 PM, revealed the following missing initials on the narcotic count sheet: -11/07/24 at 3:00 PM, the oncoming nurse did not initial the form. -11/07/24 at 11:00 PM, the off going nurse did not initial the form. -11/10/24 at 11:00 PM. -11/10/24 at 11:00 PM the off going nurse did not initial. -11/12/24 at 11:00 PM the off going nurse did not initial. -11/13/24 at 11:00 PM the off going nurse did not initial. -11/16/24 at 3:00 PM the oncoming nurse did not initial. -11/16/24 at 11:00 PM the oncoming nurse did not initial. -11/17/24 at 11:00 PM the on coming nurse did not initial. During an interview on 11/19/24 at 4:30 PM, LPN1 confirmed that there were missing initials on the narcotic sheet. She stated, I am aware that we are required to initial before coming on shift and after the shift. 2. Review of the second-floor medication cart front hall narcotic sheet with Registered Nurse (RN) 1 on 11/19/24 at 4:43 PM, revealed the following missing initials on the narcotic sheet: -11/01/24 at 7:00 AM, the off going nurse did not initial. -11/07/24 at 3:00 PM, the off going nurse did not initial. -11/11/24 the oncoming and off going nurse did not initial. -11/11/24 at 11:00 PM, the off going nurse did not initial. -11/12/24 at 7:00 AM the oncoming nurse did not initial. -11/12/24 at 3:00 PM, the off going nurse did not initial. -11/16/24 at 3:00 PM, the oncoming nursing did not initial. -11/16/24 at 11:00 PM, the off going nurse did not initial. During an interview on 11/19/24 at 4:45 PM, RN1 stated, I am aware that there needs to be sign in/sign out initial on the narcotic sheets. During an interview on 11/19/24 at 4:47 PM, Unit Manager (UM) 1 stated, I don't monitor the narcotic sheets as this is the nurses' responsibility, but they should be initialing when they come on and go off shift. 3. Review of the second-floor medication cart back hall narcotic sheet with RN2 on 11/19/24 at 4:52 PM, revealed the following missing initials on the narcotic sheet: -11/01/24 at 7:00 AM, the oncoming nurse did not initial. -11/01/24 at 3:00 PM, the off going nurse did not initial. -11/03/24 at 3:00 PM the oncoming nurse did not initial. -11/03/24 at 11:00 PM the off going nurse did not initial. -11/04/24 at 7:00 AM, the oncoming nurse did not initial; -11/04/24 at 3:00 PM the oncoming and off going nurses did not initial. -11/04/24 at 11:00 PM, the off going nurse did not initial. -11/06/24 at 11:00 PM, the off going nurse did not initial. -11/08/24 at 7:00 AM, the oncoming nurse did not initial. -11/08/24 at 3:00 PM, the oncoming and off going nurses did not initial. -11/08/24 at 11:00 PM, the off going nurse did not initial. -11/15/24 at 7:00 AM, the oncoming nurse did not initial. -11/15/24 at 3:00 PM, the oncoming nurse did not initial. -11/15/24 at 11:00 PM, the off going nurse did not initial. -11/16/24 at 3:00 PM, the off going nurse did not initial. -11/17/24 at 3:00 PM, the oncoming nurse did not initial. -11/17/24 at 11:00 PM, the off going nurse did not initial. In addition, a review of the narcotic sheet, dated 11/19/24 at 11:00 PM, RN2 had pre-signed out that the narcotic sheet was accurate despite the time not being 11:00 PM but 5:01 PM. RN2 was asked why she pre-signed out the narcotic sheet. RN2 stated, Since I am the only one who has the keys I went ahead and signed out. RN2 was asked what the standard of nursing practice dictates at the time the narcotic count was done, when you sign in/out. RN2 stated, Well, I am aware of this, but I am the only one who has the keys. During an interview on 11/19/24 at 5:01 PM, UM1 confirmed that there were missing initials on the narcotic sheets and that no pre-initialing should be done. Review of the first-floor medication cart back hall with RN3 on 11/19/24 at 5:04 PM revealed the following initials were missing from the narcotic sheet: -11/05/24 at 7:00 AM, the oncoming nurse did not initial. -11/09/24 at 11:00 PM, the oncoming nurse did not initial. -11/10/24 at 3:00 PM, the oncoming nurse did not initial. -11/18/24 at 11:00 PM, the oncoming nurse did not initial. -11/19/24 at 7:00 AM, the off going nurse did not initial. During an interview on 11/19/24 at 5:05 PM, RN3 stated, I am aware that initials are needed when coming on and going off. I don't know why there are blanks. Review of the first-floor mediation cart front hall with LPN3 on 11/19/24 at 5:06 PM revealed the following initials were missing from the narcotic sheet: -11/05/24 at 7:00 AM, the off going nurse did not initial. -11/05/24 at 3:00 PM, the oncoming nurse did not initial. -11/07/24 at 7:00 AM, the oncoming nurse did not initial. -11/07/24 at 11:00 PM, the off going nurse did not initial. -11/10/24 at 11:00 PM, the off going nurse did not initial. -11/11/24 at 7:00 AM the oncoming nurse did not initial. -11/11/24 at 3:00 PM, the off going nurse did not initial. -11/13/24 at 3:00 PM, the oncoming nurse did not initial. -11/13/24 at 11:00 PM, the oncoming and off going nurses did not initial. During an interview on 11/19/24 at 5:06 PM, LPN3 stated, I am aware that you should initial when coming on and going off. I don't know why there are no initials on the narcotic sheet. During an interview on 11/19/24 at 5:10 PM, UM2/RN5 stated, As a standard of nursing practice each nurse needs to initial after the narcotic count is done. During an interview on 11/19/24 at 5:20 PM, the Director of Nursing (DON) reviewed all of the narcotic sheets and stated, The nursing staff should be signing in/out as it's a standard of nursing practice. The DON further stated, I was not aware of the problem. Pharmacy comes in and reminds them to sign in/out, but apparently this is a problem. During an interview on 11/22/24 at 9:48 AM, the Pharmacist stated, I definitely look at the narcotic sheets, but have not done so for November yet, as I am here today to do the medication reviews. The Pharmacist further stated, It has been something I have identified in the past, and when I do, I send a report to administration. The Pharmacist was asked if pre-signing out on the narcotic sheet is acceptable. She stated, It is not acceptable practice.

Based on observation, interview, and facility policy review, the facility failed to ensure beard guards were worn during food production in accordance with professional standards for food service safety with the potential to affect 89 of 89 residents who consumed food from the kitchen. This failure had the potential for physical contamination of the food in the facility. Findings include: Review of the facility's undated policy and procedure titled, Food Safety and Preparation, revealed sanitary food preparation staff must wear gloves, hair net and beard net for facial hair if this applies to staff that has a beard . During observation of the noon meal preparation on 11/19/24 at 11:30 AM, two male kitchen staff members with beards did not have beard nets covering their beard at the food preparation station. During observation of the dinner meal preparation on 11/19/24 at 4:30 PM, two male kitchen staff members with beards did not have beard nets covering their beard at the food preparation station. During observation of the breakfast meal preparation on 11/20/24 at 7:45 AM, two male kitchen staff members with beards did not have beard nets covering their beard at the food preparation station. During observation of the noon meal preparation on 11/20/24 at 11:15 AM, while accompanied by the Dietary Manager (DM), two male kitchen staff members with beards did not have beard nets covering their beard at the food preparation station. During an interview on 11/20/24 at 11:20 AM, the DM stated that staff with beards must wear a beard net to cover their beard. I did not observe the two male kitchen staff members not wearing beard nets until I observed them today. During an interview on 11/20/24 at 11:25 AM, the Dietary Aide (DA) 3 stated, Yes, I know that I must wear a beard guard when I'm in the kitchen. I just forgot. During an interview on 11/20/24 at 11:30 AM, DA4 stated: Yes I know that I must wear a beard guard when I'm in the kitchen. I just forgot.

Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate assistance to ensure accidents were avoided for one of one resident (Resident (R) 102) reviewed for accident hazards of 40 sample residents. This failure had the potential to elevate the hazard/accident risk for all residents residing in the facility. Findings include: Review of the facility's policy titled, Mechanical Lift (Hoyer and Stand), dated January 2017 and provided by the facility, revealed two staff members must be present to utilize a mechanical lift. Review of R102's Admission Record located in the electronic medical record (EMR) under the Resident tab, indicated R102 admitted on [DATE] with diagnoses of major depressive disorder, recurrent, mild, muscle weakness, abnormal weight loss, unspecified dementia, anorexia, muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/24 located in the EMR under the Resident tab, indicated R102 had a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated the resident was severely cognitively impaired. Review of the Physician Orders, dated June 2024 and located under the Resident Tab did not indicate how R102 should be transferred. Review of the Care plan dated 05/03/24 and located under the Care Plan tab of the EMR, indicated R102 was dependent assistance x2 staff members via Hoyer lift. Review of the facility Incident Report dated 05/09/24 and provided by the facility, indicated Certified Nurse Aide (CNA) 6 transferred the resident alone and the resident's knees buckled. No injuries were sustained from the fall. R102 was care planned to be transferred via two persons using a Hoyer lift. CNA6 was suspended pending investigation. CNA6 was reported for neglect and was terminated from the facility. During an interview on 11/20/24 at 1:29 PM, the Director of Nursing (DON) stated R102 was supposed be transferred via Hoyer lift. She stated any transfer requiring a mechanical lift should have two people present during the transfer. During an interview on 11/22/24 at 11:05 AM, Licensed Practical Nurse (LPN) 4 stated she walked into R102's room and observed the resident on the fall mat. She stated R102 denied hitting her head and, CNA6 confirmed R102 did not hit her head. LPN4 stated the resident was assessed and no injuries were noted. LPN4 and CNA6 assisted R102 to the chair using a Hoyer lift. LPN4 stated R102 was supposed to be transferred using a Hoyer lift. LPN4 reported the incident to her supervisor.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure menus were followed related to portion size for four of four residents (Resident (R) 76, R84, R88, and R62) who were on a mechanical soft diet and residents receiving regular texture diets of 40 sample residents. This failure had the potential to affect the residents on the dementia unit and could result in unintentional weight loss for those residents who were nutritionally at risk without providing the appropriate meal portions. Findings include: Review of an undated document provided by the facility titled Portion Control Chart indicated the following information for scoop sizes: dark gray handle scoop capacity held one half cup; and a light gray handle scoop capacity held two thirds of a cup. 1. Review of R76's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R76's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired. Review of an untitled document provided by the facility for R76 referring to the resident's meal ticket indicated the resident was to receive DDSI (dysphasia diet standardization initiative) Level 5: Minced and Moist diet which indicated soft, moist, and easy to chew food items. 2. Review of R84's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R84's EMR significant change MDS with an ARD dated 09/29/24 with a BIMS score of zero out of 15 which revealed the resident was severely cognitively impaired. Review of an untitled document provided by the facility for R84 referring to the resident's meal ticket indicated the resident was to receive DDSI Level 5: Minced and Moist diet. 3. Review of R88's EMR Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R88's EMR admission MDS with an ARD of 07/17/24 indicated the resident had a BIMS score of zero out of 15 which revealed the resident was severely cognitively impaired. Review of an untitled document provided by the facility for R88 referring to the resident's meal ticket indicated the resident was to receive the DDSI Level 5: Minced and Moist diet. 4. Review of R62's EMR Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R62's EMR quarterly MDS with an ARD of 10/27/24 indicated the resident had a BIMS score of zero out of 15 which revealed the resident was severely cognitively impaired. Review of an untitled document provided by the facility for R62 referring to the resident's meal ticket indicated the resident was to receive DDSI Level 5: Minced and Moist diet. 5. Review of a document provided by the facility titled, Fall/Winter Menu for 2024-2025 Week One lunch meal for 11/19/24 indicated the residents, who were on mechanical soft diets, were to be served one half cup of sauteed mushrooms and onions. In addition, the residents with an order for a mechanical diet were to receive polenta, half cup. During an observation of the lunch tray line and interview on 11/19/24 at 12:39 PM, Dietary Aide (DA) 2 began to serve mechanical diets for R76, R84, R88, and R62, who resided on the Dementia unit. Each resident received one half portion of the light gray handled scoop for the polenta which was placed on the plates for the four residents. In addition, DA2 used a tong to pick up the sauteed onions and mushrooms instead of half a cup as indicated on the menu. Certified Nurse Aide (CNA) 2 stated none of the four residents were on a small portion diet. In addition, DA2 served the remaining residents, using tongs to pick up the sauteed onion and mushrooms from the serving pan and placed onto the residents' plates. Review of a document provided by the facility titled, Fall/Winter Menu for 2024-2025 Week One dinner meal for 11/19/24 indicated the residents, who were on a regular texture diet, were to be served one- and one-half cups of ravioli. During an observation and interview on 11/19/24 at 5:08 PM, DA1 was observed standing behind the steam table located on the Dementia Unit. DA1 stated residents on the mechanical soft diet were served chopped raviolis and she used a light gray scoop to serve the residents on the mechanical soft diet. DA1 then stated the residents who were on regular texture were served from a silver serving spoon and stated she served them four raviolis. During an interview on 11/21/24 at 11:04 AM, the Dietary Manager (DM) stated he had been in his position for the past three weeks. The DM stated the scoop sizes for the light gray handle scoop was one half cup instead of the designated portion size of two thirds per the Portion Control Chart. The DM stated the raviolis should have been served with an eight-ounce spoodle and given two servings. The DM presented a gray handled scoop and stated it did not have one half cup identified on the scoop. During an interview on 11/21/24 at 12:49 PM, the Registered Dietician (RD) stated the portion sizes would have come from the RD. The RD stated the scoops and spoodles were to be standardized to ensure appropriate portion size. The RD stated the residents on the Dementia unit were to have their lunch meal served with a dark gray handle, instead of the light gray handled scoop since the dark gray handled scoop served one half a cup of food. The RD stated it was important to serve the residents the appropriate serving sizes to monitor the residents' intake to ensure the residents' weights remain stable. During an interview on 11/21/24 at 3:42 PM, the Director of Nursing (DON) stated she would expect the kitchen staff to ensure the correct portion size for meals to the residents and did not want to see any residents lose weight.

Based on interview and record review, the facility failed to ensure risks vs (versus) benefits, for the use of psychotropic medications, were obtained for one of five residents (Resident (R) 3) reviewed for unnecessary medications of 40 sample residents. This failure placed residents at risk of not being informed of proposed care and treatment options. Findings include: Review of an undated facility's policy titled, Resident Rights, revealed, .The Resident has the right to exercise his or her rights as provided herein. The Facility shall ensure that the Resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the Facility. The Facility will protect and promote the rights of the Resident and support the exercising of such rights .The right to be informed of and participate in, his or her treatment, including .The right to be fully informed of his or her total health status, including diagnosis, treatment, and prognosis . Review of R3's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. Review of a Physician Order, 09/12/24 and located in the Orders tab of the EMR, revealed Escitalopram Oxalate (an antidepressant medication) give 15 mgs [milligrams] by mouth one time a day for Depression. Review of a Physician Order, 09/12/24 and located in the Orders tab of the EMR revealed, Trazadone (an antidepressant medication) give 50 mgs by mouth at bedtime related to Insomnia. Review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/18/24 revealed that R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was cognitively intact for daily decision-making and was administered antidepressant medications during the seven-day observation period. During an interview on 11/22/24 at 12:08 PM, the Director of Nursing (DON) was asked if there was documentation that R3 had been provided with the risks vs benefits for the use of the antidepressant medications, prior to being administered the medication. The DON stated, I will look for them and get back to you. At 1:15 PM, the DON was again asked if there was documentation of the risks vs benefits for the antidepressant medications for R26. The DON stated, Not yet, but still looking.

Based on record review, interviews, and review of facility policy, the facility failed to ensure one of one resident (Resident (R) 26) of 40 sample residents was allowed to self-administer cough drops per the physician order. This failure placed the resident at risk of having his right to self-administer medications violated. Findings include: Review of a facility's undated policy titled, Resident Rights, revealed .The Resident has the right to exercise his or her rights as provided herein. The Facility shall ensure that the Resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the Facility. The Facility will protect and promote the rights of the Resident and support the exercising of such rights .The right to self-administer medication if determined that such practice is clinically appropriate . Review of R26's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R26 was admitted to the facility on [DATE] with diagnoses that included chronic bronchitis and chronic obstructive pulmonary disease. Review of a Physician Order dated 03/28/23 and located in the Orders tab of the EMR, revealed Resident may keep (name withheld) cough drops at bedside and self-administer one every four hours. Review of a quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/19/24, revealed R26 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R26 was cognitively intact for daily decision-making. Review of the Care Plan, initiated on 04/06/23 and revised on 10/01/24, located in the Care Plan tab of the EMR, revealed [R26] has a physician's order for unsupervised self-administration of the following medications: (name withheld) cough drops. During an interview on 11/19/24 at 10:30 AM, R26 stated, Up in the cabinet at the nurses' station, I have a tin of over-the-counter cough drops, I have to ask the nurses to get them for me. R26 was asked if he had been assessed for safety by the nursing staff in order to have these cough drops in his room and administer them for himself. R26 stated, No, they haven't. Review of the Assessments tab and the Miscellaneous tab in the EMR did not show documentation of a self-administration assessment having been done for R26 to administer the cough drops independently. During an interview on 11/20/24 at 2:25 PM, Unit Manager (UM) 1 was asked if R26 had a tin of cough drops in the cabinet at the nurses' station. UM1 stated, Yes, they are here in the cabinet. UM1 was asked if R26 was able to self-administer the cough drops independently. UM1 stated, Yes, he is able to take the cough drops independently. He comes to me and asks for them occasionally. UM1 was asked if a self-administration assessment had been done so R26 could keep the cough drops in his room. UM1 stated, No, there has been no assessment done.

32513 46319 Based on record review, interviews, and review of facility policy, the facility failed to ensure three of six residents (Resident (R) 103, R39, R105) reviewed for abuse was free from abuse. Findings include: Review of the facility's undated policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, deprivation of goods or services, or punishment with resulting physical harm' pain or mental anguish, including such conduct facilitated or enabled through the use of technology. Physical abuse was unnecessarily inflicting pain or injury on a resident. 1. Review of R103's Resident Profile located under the Resident tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, acute embolism and thrombosis of left femoral vein, chronic obstructive pulmonary disease unspecified, other symptoms and signs involving cognitive functions following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/23 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident had severely impaired cognition. Review of a facility reported incident, dated 11/24/23 and provided by the facility, revealed that R103 stated that when she got her nebulizer treatment the morning of 11/23/23 she informed the male nurse RN6 administering it that the mask was too tight, it was hurting her, and she felt like she couldn't breathe. R103 stated RN6 told her to shut up and be quiet and proceeded to hold the mask on her face for the duration of the treatment. Review of R103's EMR Medication Administration Record (MAR), dated November 2023, indicated the R103 had received the nebulizer treatment from RN6 on 11/23/23 during the 11-7 shift. During the next shift on 11/23/23 at 6:12 PM, R103's daughter reported to the Licensed Practical Nurse (LPN) 8 that R103 received medication via the nebulizer mask which was very tight on R103s face and left red marks where the mask was. R103 and R103's daughter were crying and R103's daughter stated that R103 was afraid to stay at the facility due to the occurrence. A review of the facility incident report, provided by the facility, revealed that it was submitted to the state agency on 11/24/23 and indicated that R103 was found with red scratches/marks to her face and was fearful of RN6. RN6 failed to appropriately assess and recognize signs and symptoms of pain/discomfort and continued to provide care despite R103 attempting to resist. RN6 failed to follow physician's orders for care and did not discontinue treatment or switch to another treatment modality when R103 started to resist care. RN6 was suspended on 11/24/23 prior to working another shift and was eventually terminated on 11/29/23 at the conclusion of the facility investigation. During an interview on 11/22/24 at 10:00 AM, the Director of Nursing (DON) stated that she remembered the incident and that RN6 was immediately suspended while the facility was investigating what happened. The DON also stated that during the course of the investigation RN6 was interviewed on a couple of occasions and the description of what happened was inconsistent. The DON stated on 11/29/23, RN6 was terminated for the alleged abuse. 2. Review of R39's annual MDS located under the MDS tab of the EMR with an ARD of 10/25/23, revealed the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The resident received hospice care and passed away on 11/16/24. Review of R39's written statement, dated 10/14/24 and provided by the facility, revealed that R39 has had multiple altercations with CNA [Certified Nurse Aide (CNA) 12] but we always make up. R39 stated that they could hear CNA treat other patients and was scared to say anything to get CNA in trouble. I used the call bell around 8:30 AM and told CNA that I had a bowel movement. CNA stated I'm busy and will come back later. I waited 20 or 30 minutes. Ring the call bell again. CNA stated, Why did you hit the call bell again, I told you I was coming back-I'm buried. Could hear CNA screaming in the hallway but could not make out what was being said. I was very upset; I did keep hitting the call bell because CNA would not change me. Stated that she was too busy. During an interview on 11/21/24 at 12:45 PM, CNA9 agreed that the written statement (The email regarding CNA12), dated 10/15/24, about the involvement with R39 and CNA12 was accurate and truthful. CNA9 stated that CNA12 did state Somebody better come and get resident before I punch resident in the face. During the interview on 11/21/24 at 1:05 PM, LPN7 confirmed an investigative report, dated 10/12/24, into the involvement with R39 and CNA12 was accurate and truthful. LPN7 stated CNA12 told her Somebody better come and get resident before I punch resident in the face. She stated that CNA12 further stated I didn't mean anything. LPN7 stated the allegation was substantiated. She stated the disciplinary action was termination, but CNA12 resigned via email on 10/15/24. LPN7 stated R39 was informed of the outcome of the investigation and answered all questions. During the phone interview on 11/21/24 at 1:38 PM, CNA12 confirmed that the written statement, dated 10/15/24, about the involvement with R39 was accurate and truthful. CNA12 explained: I was just frustrated and lashing out. I was little burnt out, and I take full responsibility for my actions. I wasn't even by the resident's room. During an interview on 11/21/24 at 1:00 PM, the Social Services Director (SSD) stated that R39 had periods where CNA12 was not kind. SSD stated that R39 said CNA12 asked to be taken off his assignment. 3. Review of R105's Admission Record located in the Profile tab of the EMR revealed R105 was admitted to the facility on [DATE] with diagnoses that included a urinary tract infection, lumbar (lower spine) fracture, and seizures. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 02/04/24 revealed R105 had a BIMS score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. Review of a Progress Note, dated 02/22/24 and located in the Progress Notes tab of the EMR, revealed .Discharge Plan: SW (social worker) met with resident, Resident requesting to go home. Resident stated she feels like her mental health cannot get better in rehab. Rehab director explained that resident could use additional time, resident refused. SW spoke with resident caregivers who agreed to discharge for 2/23/24 . Review of a Facility Abuse Investigation, dated 02/23/24 and provided by the DON, revealed .02/22/2024 @ 10:30 AM .Abuse, Mistreatment .Accused: Staff .Resident stated her cna (sic) disrespected her made her feel demoralized and throws clothing at her when it is time to get dress (sic). Resident stated cna (sic) points her finger (does not speak) and motions when she want (sic) resident to turn over. Also stated cna (sic) is loud in the hallways (shouting). Resident stated its not good for my mental health. Resident afraid of retaliation. The resident is clear and consistent in naming [CNA13] as the cna. Outcome of the investigation revealed, [CNA13] was suspended pending investigation on 02/22/24 and was terminated on 02/28/24, for interfered (sic) with an ongoing resident concern investigation, disrespectful conduct on nursing unit in front residents, staff, and family (towards administrator) and inappropriate interactions considered verbal intimidation. [R105] was informed of the outcome of the investigation. During an interview on 11/22/24 at 11:23 AM, Human Resources (HR) was asked to define verbal intimidation in the investigation. HR stated, Verbal intimidation is considered verbal abuse in our eyes. During an interview on 11/22/24 at 1:02 PM, the DON stated she hadn't looked at the investigation in some time, but the allegation of abuse was substantiated.

Based on record review, interview, and facility policy review, the facility failed to protect two of two residents (Residents (R) 17 and R95) from misappropriation of property of 40 sample residents. This failure has the potential to affect all residents who choose to keep money and/or credit cards in their rooms. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime indicated the following: .Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 1. Review of R17's Resident Profile located in the electronic medical record (EMR) under the Resident tab, indicated R17 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, obstructive sleep apnea, diabetes mellitus due to underlying condition with diabetic chronic kidney disease, and muscle weakness. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/09/24 revealed R17 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. During an interview on 11/19/24 at 1:55 PM, the Director of Nursing (DON) stated R17 received her credit card statement for July 2024 with charges on it that she didn't make. She reported this to the state and police. She stated a Certified Nurse Aide (CNA) 16 who worked at the facility stole the card. The DON stated an investigation was completed and CNA16 was terminated. During an interview on 11/19/24 at 3:45 PM, R17 stated she believed the credit card number was taken off the bill she had on her dresser. She stated there were eight to 10 unauthorized charges on the bill. She stated she did not know who took the credit card number and used it. R17 stated the facility administrative staff reported this issue to her about her card being used. She denied any further issues since that time. Review of the [Facility Name] General Orientation Record provided by the Administrator, revealed CNA16 received education on 06/20/24 regarding abuse, neglect, exploitation, and misappropriation of resident property. 2. Review of R95's Admission Record located under the Resident tab of the EMR revealed R95 was admitted on with diagnoses of malignant neoplasm of colon, cellulitis, secondary malignant neoplasm of liver and intrahepatic bile duct, and major depressive disorder. Review of the significant change MDS with an ARD of 08/27/24, revealed R95 had a BIMS of eight out of 15 indicating the resident was moderately cognitively impaired. During an interview on 11/19/24 at 11:56 AM, R95 stated a credit card was stolen and a charge for $45 was on the card that he did not make. He stated the card was locked by the bank. Review of CNA16's employee file revealed she was observed on camera picking up the food she purchased with stolen credit cards from the residents. On 07/22/24, the Administration team was informed a resident was missing a sum of money from a bank account. Purchases were made on 07/19/24 and 07/20/24 from the restaurant in question and delivered to the facility. Review of CNA16's termination letter revealed the following: Under Delaware Title 16, this is defined as Financial exploitation' [ .] the illegal or improper use of a patient's or resident's resources for financial rights by another person, whether for profit or other advantage. Review of the facility Incident Report, dated 10/03/24 and provided by the facility, revealed video recordings of CNA16 picking up the food. During an interview on 11/19/24 at 1:55 PM, the DON stated the perpetrator used R95's debit card on two separate occasions 07/19/24 and 07/20/24. She stated the resident, and his sister confirmed there were unauthorized charges on the debit card. The DON stated the facility had completed an investigation and reported the incident to the police. Review of CNA16's written statement, dated 07/31/24 and provided by the facility, indicated CNA16 stated the food items were ordered and her phone number was used. During an interview on 11/22/24 at 7:43 AM, The DON stated residents could secure their money, credit cards, and valuables in their nightstands. She stated maintenance could put a lock on the drawer and provide a key to the residents.

Based on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of potential abuse was reported to the State Survey Agency (SSA) in a timely manner for one of five residents (Resident (R) 108) reviewed for abuse/neglect of 40 sample residents. This failure had the potential for other allegations of abuse/neglect not to be reported in a timely manner. (Cross Reference F741) Findings include: Review of a facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation and Reasonable Suspicions of Crime dated 10/19 indicated .Witnessed or suspected incidents of abuse are to be reported immediately .neglect, mistreatment . Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours . Review of R108's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R108's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/23 indicated the facility staff could not determine the resident's Brief Interview for Mental Status (BIMS) score and revealed the resident had short-and-long-term memory problems. The assessment indicated the resident had no behavior during this assessment period. The assessment indicated the resident required one staff member's assistance for toileting. Review of R108's EMR Care Plan located under the Care Plan tab, dated 12/04/21, indicated the resident had a self-care deficit related to dementia. The care plan interventions revealed when the resident was incontinent, she required partial/moderate assistance from staff with hygiene. Review of a document provided by the facility titled, Alleged Abuse, dated 10/13/23, indicated Certified Nurse Aide (CNA) 1 informed the MDS Coordinator (MDSC) that R108 sustained a skin tear during the provision of care. The MDSC identified skin tears and multiple bruised areas on the resident's bi-lateral arms and wrists. Review of a document provided by the facility titled, Delaware Health & Social Services Division of Health Care Quality, dated 10/13/23, revealed the facility determined on 10/13/23 at 7:30 PM the incident between CNA1 and R108 was a potential allegation of mistreatment. The document indicated the allegation was reported to the SSA on 10/13/23 at 11:14 PM. During an interview on 11/20/24 03:12 PM, the MDSC confirmed she was the staff member who completed the initial skin assessment of R108. The MDSC stated she escalated the staff to resident incident due to potential abuse and reported the allegation immediately to the Director of Nursing (DON). The MDSC stated the allegation was to be reported to the SSA within two hours but failed to do so. During an interview on 11/22/24 at 1:06 PM, the Administrator stated any allegation of abuse/mistreatment was to be reported to the SSA within two hours.

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident (Resident (R) 36) of 40 sample residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. Findings include: Review of the RAI manual, dated 10/24 and located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS, revealed .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . Review of R36's electronic medical records (EMR) Admission Record located under the Profile tab indicated the resident was admitted on [DATE]. Review of R36's EMR nursing Incident Report progress note located under the Prog (Progress) Note tab, dated 07/18/24, indicated that a Certified Nurse Aide (CNA) alerted the nurse that R36 sustained a fall from her wheelchair. According to the progress note, the CNA informed the nurse that she was getting the resident ready for bed and before she could get to the resident, the resident tossed a pillow and fell from her wheelchair and hit her head. The nurse notified the physician, and the physician informed the nurse to have the resident transported to the local hospital. Review of R36's EMR nursing Incident progress notes, located under the Prog Note dated 7/18/24, indicated a CNA alerted the nurse that the resident fell from her wheelchair onto the floor. The progress notes indicated the resident sustained swelling to her forehead. The physician was notified and ordered that the resident be sent to the local hospital for evaluation and treatment. Review of R36's EMR nursing Admission progress notes, located under the Prog Note tab, dated 07/24/24, indicated the resident returned from the hospital. Review of R36's EMR significant change MDS with an Assessment Reference Date (ARD) of 08/08/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired. The assessment failed to address that the resident sustained a fall during this assessment period. During an interview on 11/21/24 at 12:25 PM, the MDS Coordinator (MDSC) verified that the significant change MDS did not reflect R108's fall sustained on 07/18/24. The MDSC stated the purpose of the resident's significant change MDS was related to the fall that the resident sustained.

.Based on observations, interviews, and record review, the facility failed to ensure activities of daily living (ADLs) were provided consistently according to the plan of care for two of six residents (Residents (R) 93 and R23) reviewed for ADLs of 40 sample residents. The facility failed to ensure R23 was provided with oral hygiene and R93 was provided with consistent showers twice weekly. This failure placed the residents at risk of a diminished quality of life. Findings include: 1. Review of R93's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R93 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/26/24 revealed that R93 had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R93 was severely impaired in cognition. Review of the ADL Care Plan located in the Care Plan tab of the EMR, initiated on 04/17/24 and revised on 05/04/24, revealed [R93] has an ADL self-care performance deficit r/t [related to] dementia and functional quadriplegia (complete immobility due to severe disability or frailty). Review of the Point of Care (POC-Certified Nurse Aide (CNA) documentation located in the Tasks tab of the EMR, revealed that R93's showers were not documented as having been done or if the resident had refused on the following dates: 08/22/24, 09/02/24, 09/19/24, 10/03/24, 10/10/24, 10/14/24, 11/04/24, 11/07/24, 11/11/24 and 11/14/24. There was no documentation of the resident receiving or refusing bed baths. During an interview on 11/21/24 at 12:48 PM, Licensed Practical Nurse (LPN) 4 was asked how she monitored resident showers to ensure they were being given, according to the Plan of Care. LPN4 stated, When a shower is not given, the nurse is to be informed. If a shower is refused, we would go to the residents and ask why they are refusing. If they continue to refuse, it is documented, and the family is notified. LPN4 further stated that R93's shower days were Monday and Thursday on the 3:00 PM to 11:00 PM shift. During an interview on 11/21/24 at 3:12 PM, CNA13 was asked what her process was with regards to making sure residents received their showers. CNA13 stated, I get my shower assignment when I come on duty which is in the assignment book. If a resident takes the shower and/or refuses, I tell the nurse, and it's documented in the POC. I can't answer as to why his showers were not done. During an interview on 11/22/24 at 10:29 AM, Unit Manager (UM) 1 stated, I went over the showers that were documented for [R93] and found the days he did not get his showers, this was a problem. UM1 was asked what her expectation was regarding ensuring residents received their showers according to the Care Plan. UM1 stated, My expectation is that residents receive their showers according to the schedule and the nurses are informed when there is a refusal. During an interview on 11/22/24 at 12:45 PM, the Director of Nursing (DON) stated, The resident showers are to be documented if given and if there is a refusal, to let the nurse know so they can speak to the resident. 2. Review of R23's Admission Record located in the Profile tab of the EMR revealed R23 was admitted to the facility on [DATE] with diagnoses that included a stroke with right-sided paralysis and vascular dementia. Review of the quarterly MDS assessment located in the MDS tab of the EMR with and ARD of 10/11/24 revealed, R23 had a BIMS score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. In addition, R23 had limited range of motion on both upper and lower extremities on one side. Review of the Dental Care Plan located in the Care Plan tab of the EMR, dated 10/15/22 and revised on 04/22/23, revealed [R23] has own natural teeth with breakdown and is at risk for complications. She had a tooth extracted on 03/29/23. A 10/15/22 approach revealed Provide mouth care as per ADL personal hygiene. Review of the ADL Care Plan located in the Care Plan tab of the EMR, dated 07/14/22 and revised on 06/27/24, revealed [R23] has an ADL self-care performance deficit r/t Dementia, Impaired balance, Limited Mobility, Stroke. There were no documented approaches for oral hygiene on the ADL Care Plan. During an observation and interview on 11/19/24 at 1:34 PM, R23 was observed to have a significant amount of brown coating across both her upper and lower teeth. R23 was asked if staff assisted her to brush her teeth. R23 stated, Sometimes they do. Review of the POC Response History-Oral Hygiene located in the Task tab of the EMR, revealed that R23 was dependent on staff (Dependent is defined as Helper does all of the effort and resident does none of the effort to complete the activity) in order to meet her oral hygiene needs. Documentation showed that from 07/21/24 to 11/21/24 (124 days) R23 required only set up assistance once, required supervision for four opportunities, partial or moderate assistance for four opportunities, extensive assistance for seven opportunities, and was dependent on staff for oral hygiene for 208 opportunities. During an observation and interview on 11/22/24 at 10:33 AM, UM1 observed R23's teeth. UM1 confirmed that her teeth had not been brushed and there was a coating on her teeth. UM1 further stated, It's been a while since her teeth were brushed. During an interview on 11/22/24 at 12:52, the DON stated, [R23] can brush her own teeth after staff put the toothpaste on her electric toothbrush. The DON was informed that the documentation in POC revealed that R23 was dependent on staff for oral hygiene. The DON stated, She should be extensive assistance and not dependent on staff.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one Licensed Practical Nurse (LPN) 1, who identified a skin alteration for one of two residents (Resident (R) 36's) reviewed for wound care, notified the Primary Care Physician (PCP) for treatment orders. In addition, the facility failed to ensure a physician ordered blood pressure was obtained prior to administering a hypertensive medication for one of five residents (Resident (R) 109) observed during the medication pass of 40 sample residents. This failure placed residents at risk for health complications. Findings include: Review of the facility's policy titled, Provider Notification of Resident Change in Medical Condition, dated 04/17, indicated .It is the policy of [Facility Name] Rehabilitation and Healthcare Center that staff communicate changes in a resident's medical condition to providers in a timely and accurate manner . Review of the facility's undated policy titled, Pressure Ulcer Identification indicated .Resident will be assessed for timely identification and interdisciplinary intervention for the care and treatment of pressure ulcers.New wound alert form will be completed by the nurse identifying the wound and forward as indicated . Review of the facility's policy titled, Medication Administration, dated 2023, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, time . 1. Review of R36's electronic medical record (EMR) Admission Record indicated the resident was admitted to the facility on [DATE]. Review of R36's EMR Care Plan located under the Care Plan tab, dated 09/19/24, indicated the resident had an unstageable pressure ulcer on the right heal related to the disease process, poor nutritional intake, and immobility. No mention of the right ankle abrasion. Review of R36's EMR significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/24 indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score and determined the resident had short-and-long-term memory problems. The assessment indicated the resident had no impairments on her upper and lower body extremities. The assessment revealed R36 was dependent on staff for activities of daily living. Review of R36's EMR Order Note, dated 11/19/24, revealed LPN1 noted a new wound to the resident's right ankle. Review of R36's EMR physician Orders located under the Orders tab failed to indicate orders were obtained to treat the new wound on the resident's right ankle. Review of a document provided by the facility titled Physician Communication Record for R36 failed to indicate LPN1 communicated to the resident's primary care physician (PCP) the new wound identified on the resident's right ankle. During an interview on 11/21/24 at 8:25 AM, Registered Nurse (RN) 4 stated R36's boot was taken off daily for hygiene. During an observation and interview on 11/21/24 at 8:30 AM, RN5 (who was the facility's wound nurse) and the Wound Doctor entered R36's room. The resident was in her bed. The Wound Doctor lifted the blankets from the resident's lower leg and removed a white removeable splint from the right leg. The Wound Doctor treated the resident's right. After the dressing was applied to the resident's right ankle, the Wound Doctor stated there was a skin abrasion on the resident's right ankle and was not aware of the abrasion. The Wound Doctor stated the abrasion was caused by the leg splint. There was no dressing observed on the resident's right ankle. The Wound Doctor stated he was going to treat the resident's right ankle like it was a wound. During an interview on 11/21/24 at 11:29 AM, RN5 confirmed she was notified of R36's abrasion of her right ankle today and was informed of the area by the Director of Nursing (DON). RN5 went through the resident's EMR and confirmed there were no orders to treat the right ankle abrasion. RN5 stated the expectation for a new skin area was to notify the physician and begin treatment. During an interview on 11/21/24 at 11:49 AM, R36's PCP was interviewed, and she stated she did not remember being notified of the resident's right ankle abrasion. During an interview on 11/21/24 at 4:02 PM, LPN1 stated she just completed a skin assessment and did not make the resident's PCP or the wound team aware of the resident's right ankle. The DON was present during this interview and after the interview with LPN1, the DON stated LPN1 missed a few steps and did not notify the physician and the family, in addition, the DON stated a wound alert form was not completed. The DON stated the facility only had pressure ulcer policies and not general skin policies. 2. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R109 was admitted to the facility on [DATE] with diagnoses that included hypertension and an irregular heart rhythm. Review of the Physician Orders, dated 11/08/24 and located in the Orders tab of the EMR revealed, Olmesartan [a blood pressure medication] give 20mg every day. Hold if SBP [systolic blood pressure] <120. During a medication pass observation on 11/21/24 at 8:50 AM, LPN7 was observed to have punched out the medication from a bubble pack, and along with her other medications, proceeded to enter R109's room to administer the medication. LPN7 was stopped and asked if she had obtained R109's blood pressure prior to administration per the label on the bubble pack. LPN7 stated, It's not on her MAR [medication administration record] and does not pop up to alert us not to give the medication without obtaining a blood pressure. Review of the blood pressures documented in the Weights and Vitals tab of the EMR from admission, with LPN7, revealed no documented blood pressures had been obtained at the time the medication was administered on nine occasions. The blood pressures had been obtained on the night shift however, it was not taken on the day shift when the medication was administered. LPN7 confirmed that the blood pressures had not been obtained prior to administration on the day shifts. During an interview on 11/21/24 at 9:38 AM, the DON stated, The Physician Order does indicate holding the medication if the SBP <120 as well as on the MAR. The DON confirmed that the heart icon on the MAR was missing which would have allowed the nurses to document the blood pressure prior to administration. The DON further stated that after the physician entered the medication into the system, RN7 would have to confirm the order however, she did not include the supplemental documentation to include blood pressure. During an interview on 11/21/24 at 3:47 PM, RN7 confirmed that she did not include the supplemental documentation in the system to include holding the medication if the SBP was <120. During an interview on 11/22/24 at 9:51 AM, the Pharmacist stated that R109 was a new admission, so her medication review had not been done. The Pharmacist further stated, When I do my medication cart rounds and see the discrepancies, I would bring that information to administration via my reports. 32513

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure nail care was provided to one of one resident (Resident (R) 1) reviewed for nail care of 40 sample residents. This had the potential to limit mobility for R1 or cause R1 pain if the nails were left untreated. Findings include: Review of the facility's policy titled, Nails, Care of Finger and Toe, dated May 2023, indicated . PURPOSE . To provide cleanliness . To prevent spread of infection . Review of an undated Face Sheet, provided by the facility, indicated R1 was admitted to the facility on [DATE], with diagnoses of abnormalities gait, muscle weakness, and lack of mobility. Review of the five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. The assessment revealed R1 required limited assistance of one staff member for personal hygiene. During an observation conducted on 11/20/24 at 11:05 AM, R1 removed bed sheets to expose lower extremities, including the feet. On both feet, the toenails were uncut, and the nails extended beyond the tip of the R1's toes. During an interview on 11/20/24 at 11:23 AM, R1 stated that since being admitted to the facility, she had been requesting a podiatry appointment. She could not remember who she asked, but R1 stated that she had asked several staff members. During an observation and interview conducted on 11/21/24 at 9:15 AM, R1's bed sheets were removed to expose lower extremities, including the feet. On both feet, toenails were uncut, and the nails extended beyond the tip of the R1's toes. Registered Nurse (RN) 5 was unaware that both left and right foot nails were uncut to where they extended beyond the tips of the R1's toes. During an interview on 11/21/24 at 9:15 AM, RN5, stated staff would ask if residents required podiatry care and gave the referrals to her. RN5 stated she would make podiatry appointments at that time. She stated the facility used podiatry because staff did not cut toenails. RN5 stated that R1 did not complain about her toenails, nor did any staff member tell her about R1 needing podiatry. RN5 stated if a resident needed to have their toenails done, she would make the appt. During an interview on 11/21/24 at 7:29 AM, Certified Nurse Aide (CNA) 17 confirmed staff could not trim a resident's toenails. CNA17 stated she informed RN5 when a resident needed their toenails trimmed, and RN5 would make the appointment. CNA17 also stated that R1 told her that an appointment had been made for her toenails. She stated that it was about two weeks ago. CNA17 stated she did not tell anybody about the conversation or follow up if this was done. During an interview on 11/21/24 at 7:45 AM, CNA18 who had completed personal care for R1 confirmed not knowing R1's toenails needed trimming. During an interview on 11/21/24 at 8:05 AM, CNA19 who had completed personal care for R1 confirmed not knowing R1's toenails needed trimming. During an interview on 11/22/24 at 12:21 PM, the Director of Nursing (DON) stated the facility made appointments for podiatry. She stated the facility required all residents to be seen by a podiatrist. She also stated the facility audited skin frequently and the goal for nail care was to prevent infection.

Based on observations, record reviews, interviews, and review of facility policies, the facility failed to ensure one resident (Resident (R) 36) was provided adaptive equipment (padded footrest) that was attached to her wheelchair and failed to ensure one of two residents (R23) was consistently provided with a physician ordered splint to her right arm/hand of 40 sample residents. This failure placed the residents at risk of improper support, positioning, and at risk of further decreased range of motion (ROM) and worsening contractures (a condition of shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints). Findings include: Review of the facility's policy titled, Repositioning, dated 03/16, indicated .Lifting/handling and other assistive devices will be used whenever determined based on the practitioner order . Review of the facility's policy titled, Splints and Position Devices, dated 05/16, indicated .All residents are screened by therapy on admission for contractures and/or limitations in range of motion.Based on evaluation, specialized devices, such as, knee immobilizers or custom splinting may be requested through the Rehabilitation Department. Rehab will obtain these devices and provide instructions on application . 1. Review of R36's electronic medical record (EMR) Admission Record located under the Profile tab of the EMR indicated the resident was admitted to the facility on [DATE]. Review of R36's EMR Incident Note located under the Prog Notes tab, dated 07/25/24, revealed the resident was identified with a fracture of her right tibia/fibula. The resident was sent to the local hospital and returned back to the facility on the same date, with conservative treatment ordered (no surgical repair per family request). Review of a document provided by the facility titled Physical Therapy Treatment Encounter Note, dated 07/29/24, indicated R36 was seen sitting in her wheelchair and her leg rests were adjusted and it was noted by the physical therapist, that the resident would take her legs off the leg rests and recommended a calf and foot board to allow relaxation of her legs on the leg rests and to avoid further trauma to the resident's lower extremity. Review of a document provided by the facility titled, Occupational Therapy Treatment Encounter Note, dated 07/29/24, indicated R36 was provided with a high back reclining wheelchair with elevating leg rests and seat cushion to promote proper positioning and postural alignment during out of bedtime . Review of R36's EMR Care Plan located under the Care Plan tab, dated 10/28/24, indicated the resident had limited physical mobility related to muscle weakness. The care plan failed to address the resident required the use of a high back wheelchair and a padded footrest to assist the resident with positioning. During an observation on 11/19/24 at 3:46 PM, R36 was sleeping in her high back wheelchair. There was a Roho cushion on the seat of the wheelchair, and there were padded footrests attached to the feet of the wheelchair. During an observation on 11/20/24 at 1:55 PM, R36 was observed sitting in a standard wheelchair and no padded footrests were attached to the feet of the wheelchair. During an observation and interview on 11/20/24 at 5:06 PM the Director of Rehabilitation (DOR) stated R36 was picked up for skilled therapy by Physical and Occupational therapies after her fracture was identified. The DOR confirmed the therapy department recommended a padded footrest for the resident after her hospital stay. At 5:17 PM, the DOR and surveyor went up to the Dementia Unit and observed the resident in the main dining room, sitting in a standard wheelchair and confirmed the resident did not have padded footrests attached. The resident was observed with a brace on her right lower leg, and it was resting on one of the footrests. The left foot had dropped between the two footrests. At 5:18 PM, Certified Nurse Aide (CNA) 2 (day shift) confirmed she did not have R36 placed in a high back wheelchair and did not place the padded footrests on the standard wheelchair. The DOR was present during this interview. Registered Nurse (RN) 4 was present during this observation and interview. An interview was conducted at 5:18 PM, with CNA3 (works the evening shift) and stated the resident typically had footrests on the wheelchair but did not know why they were not presently on the resident. At 5:19 PM, DOR and the surveyor entered R36's room and found her high back wheelchair in the bathroom along with the padded footrests. During an interview conducted on 11/20/24 at 5:23 PM, the DOR stated the padded footrests were for positioning as well as the high back wheelchair. During an interview on 11/20/24 at 5:27 PM, RN2 stated R36 required the use of padded footrests. RN2 went into R36's EMR and verified that there was no reference in the Treatment Administration Record (TAR) which would potentially track placement of the resident's padded footrests. During an interview on 11/20/24 at 6:03 PM, the DOR stated R36's high back wheelchair allowed the resident for a more comfortable position. The DOR stated the padded footrests would prevent the resident's feet from slipping past the footrests and allowed the resident to have proper sitting and positioning with the ankle and foot. 2. Review of R23's Admission Record located in the Profile tab of the EMR revealed R23 was admitted to the facility on [DATE] with diagnoses that included a cerebral vascular accident (CVA-stroke) with right-sided paralysis. Review of a Physician Order dated 03/04/24 and located in the Orders tab of the EMR revealed, Right hand splint to be applied at HS [hour of sleep] and worn throughout the night-if resident complains of pain or discomfort, it is ok to remove splint A and apply splint B. If splint A needs to be removed for comfort, the splint should be sent to her OT [occupational therapist] for any modifications that might need to be made. Review of a Physician Order dated 03/05/24 and located in the Orders tab of the EMR, revealed Splint A to be worn 6-8 hours during the day. Apply Splint A in the morning at 0900 [9:00 AM]. Remove Splint A at 1700 [5:00 PM] and perform a skin check to area. Notify MD [Medical Doctor] of any redness or irritation caused by the splint. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/11/24 revealed R23 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R23 was cognitively intact for daily decision-making and had limited range of motion on one side involving both upper and lower extremities. Review of the ROM Care Plan located in the Care Plan tab of the EMR with an initiated date of 08/04/22 and revised on 10/14/24, revealed [R23] has a moderate limitation of her right shoulder and right elbow. She also has moderate limitation of her right wrist and right ankle. Resident is at risk of developing new and/or worsening contractures and/or limitation in motion secondary to CVA and muscle weakness. Rehab assessment last completed on 09/17/24. During an observation on 11/19/24 at 1:48 PM, R23 was sitting up in the recliner. There was no splint observed to her right arm and hand. During an observation on 11/20/24 at 9:00 AM, R23 was in bed, and being assisted to eat. There was no splint on her right arm or hand. During an interview on 10/21/24 at 10:21 AM, R23 was asked if the splint to her right arm/hand was applied consistently every morning. R23 stated, Sometimes yes, sometimes no. R23 was asked if her nighttime splint was applied nightly. R23 stated, Sometimes. Review of the Treatment Administration Record (TAR) dated November 2024 and located in the Orders tab of the EMR, revealed from 11/19/24 to 11/22/24, Splint A was not documented as having been applied on 11/19/24 at 9:00 AM however, it was documented that Splint A was removed at 9:00 PM. On 11/20/24, 11/21/24, and 11/22/24, the documentation showed that Splint A was applied at 9:00 AM and removed at 9:00 PM. During an interview on 11/22/24 at 10:44 AM, Unit Manager (UM) 1 was asked what her expectation was regarding splint placement. UM1 stated, My expectation is that if there is a physician order for a splint/brace, then it needs to be applied. UM1 and this surveyor went to R23's room. UM1 confirmed that R23 did not have the splint on, as ordered. During an interview on 11/22/24 at 12:52 PM, the Director of Nursing (DON) was told about the observations with R23 not having her splint on, as ordered. The DON stated, My expectation is that nursing is to put the splint on, but she does refuse sometimes. 32513

Based on observations, record review, interviews, facility document review, and facility policy review, the facility failed to ensure residents were provided with appropriate dementia care interventions from one of one Certified Nurse Aide (CNA) 1 resulting in one of one resident (Resident (R) 108) sustaining harm with visible bruising, skin tears, and complaints of pain of 40 sample residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of a facility's document titled Facility Assessment, dated 10/22/24 and provided by the facility, indicated under a section titled Staff Competencies revealed .Competencies for Certified Nurse's Aides (CNA) include the following .Behavioral Management . Review of a facility's policy titled, Dementia Care, dated 2023, indicated .It is the policy of this facility to provide the appropriate treatment and services to every resident who has signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being .The care plan will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals .Care and services will be person-centered and reflect each resident's individual symptomology .All staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill set to ensure residents' safety and help resident's attain or maintain the highest practicable physical, mental, and psychosocial well-being . Review of R108's electronic medical record (EMR) titled Admission Record located under the Profile indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia, mood disturbance, and anxiety. Review of R108's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/23 indicated the facility staff could not determine the resident's Brief Interview for Mental Status (BIMS) score and revealed the resident had short-and-long-term memory problems. The assessment indicated the resident had no behavioral issues during this assessment period. The assessment indicated the resident required one staff member's assistance for toileting. Review of R108's EMR Care Plan located under the Care Plan tab, dated 10/14/22, indicated the resident had a history of becoming physically aggressive with staff during the provision of care. The interventions of the care plan included attempting to provide an alternate time to provide care if refused, to remove the resident from the situation if she became agitated and utilize diversion techniques as needed. Review of a document provided by the facility titled Alleged Abuse, dated 10/13/23, indicated Certified Nurse Aide (CNA) 1 informed the MDS Coordinator (MDSC) that R108 sustained a skin tear during the provision of care. The MDSC was the previous nurse supervisor on this date. According to the facility's investigation, R108 told the MDSC that she was grabbed and hurt. The MDSC documented the following injuries after CNA1's previous encounter: on the right upper arm the resident sustained a skin tear which measured 1.2 centimeters (cm) by 0.3 cm; on the left hand the resident sustained two small skin tears which measured 0.5 cm by 0 cm and 0.5 cm by 0.1 cm; the resident sustained bruising on her right upper arm which measured 4.5 cm by 5 cm; the resident sustained bruising on her right forearm which measured 5 cm by 4.5 cm; the resident sustained bruising on her right wrist which measured 15 cm by 10.2 cm; and the resident sustained bruising on her left arm which measured 18 cm by 10.5 cm. The facility's investigation included a written statement provided by the facility from Licensed Practical Nurse (LPN) 1, dated 10/13/23. LPN1 documented she had returned from her lunch break and was asked by the MDSC to accompany her to R108's room. LPN1 documented both she and the MDSC assessed the resident's skin. LPN1 noted that the resident had bruising on her right and left wrists and her skin was red. LPN1 noted that R108 had a skin tear to her left wrist and complained of being in pain while the resident pointed to her bruises. LPN1 stated she medicated the resident with acetaminophen for her pain. As part of the facility's investigation, the MDSC asked CNA1 to complete a Skin Tear Investigation, dated 10/13/23. CNA1 documented she held R108's wrists so she could clean between her legs. CNA1 wrote in her statement that the resident was confused, combative and slapped and hit her. CNA1 wrote that she was the one who caused the resident's skin tear during the provision of care. The facility immediately suspended CNA1 and began to interview multiple other staff about the incident. A review of CNA1's employee record, provided by the facility, was conducted. The file indicated CNA1 was hired on 08/03/23. Review of a document provided by the facility titled, Employee Status Change Notice revealed CNA1 was terminated by the facility due to failure to provide R108, who had dementia, with proper dementia care as directed by the dementia care training she received from the facility. The document also indicated the resident sustained bruising on both arms and a skin tear. During an interview on 11/20/24 at 12:49 PM, Registered Nurse (RN) 4, stated if a resident was aggressive during cares, the CNAs were directed to make sure the resident was safe and to step away and approach the resident at another time. During an interview on 11/20/24 at 1:03 PM, CNA2 stated she remembered R108 and stated she was very sweet with staff who would speak to her in a kind manner. CNA2 stated if a resident was aggressive during care, the CNAs were directed to give her a break. CNA2 stated the resident was able to move around and stand with stand-by assistance. During an interview on 11/20/24 at 3:12 PM, the MDSC stated she was the staff member who CNA1 reported the skin tear to. The MDSC confirmed the resident was in pain and the bruises and the skin tear were evident. The MDSC stated R108 reported to her that a woman grabbed her, and the resident stated she did not know who the woman was. The MDSC stated residents with dementia could be pleasant or not so pleasant and require more patience from the staff. The MDSC stated that when a resident had dementia, we see their physical disabilities and we need caregivers who are understanding. The MDSC stated if a resident became combative during care, the staff were to ensure the resident was safe, leave, and then reapproach at a later time. The MDSC stated she had CNA1 demonstrate what happened, and per the MDSC, CNA1 grabbed her wrists to show this was what she did with R108. During an interview on 11/21/24 at 4:05 PM, the Director of Nursing (DON) stated CNA1 was trained in dementia care and worked with difficult behaviors. During an interview on 11/22/24 at 12:38 PM with the Administrator and DON, the Administrator stated it was important to have the caregiving staff trained in dementia care since that was the majority of the population in the facility. The Administrator stated CNA1 should have stopped care for R108 and walked away.

Based on interviews, review of clinical records and facility documentation as indicated, it was determined that for one (R1) out of five residents reviewed for death in the facility, the facility failed to ensure that Nursing personnel provided basic life support (CPR) to a resident who was a Full Code. On [DATE] at 11 PM, R1 was found unresponsive in his room and nursing personnel failed to check R1's code status, failed to call a Code Blue, failed to initiate CPR and failed to activate the Emergency Response System (EMS) by calling 911. R1 expired and the RN pronounced R1 as deceased . Due to the facility's corrective measures following the incident, this is being cited as an immediate jeopardy, past non-compliance with an abatement date of [DATE], which was verified by interviews and review of facility records. Findings include: Cross refer to F609 and F726 The facility's policy entitled Code Blue ([CONDITION(S)]), effective [DATE], stated: . Purpose: To provide cardiopulmonary resuscitation (CPR) for those residents who are designated as a 'Full Code' . Scope and Responsibility: This policy applies to ALL personnel. Early Cardiopulmonary Resuscitation is an important link in the chain of survival for a victim of sudden cardiac or respiratory arrest. Therefore, every employee is responsible to respond immediately and to summon help loudly. Employees certified in CPR will initiate . (CPR). CPR will provide oxygenated blood to the brain and other vital organs until the advanced medical treatment team arrives. Procedure: 1. Check the victim for responsiveness . 2. If the person is unresponsive, call loudly, I need help in room_____ . 3. Instruct the first responder to notify the charge nurse and activate the Emergency Response System (EMS), by calling 911, and to obtain the Automatic External Defibrillator (AED) located at the Nurse's Station . 4. Stay with the victim and begin CPR . 5. Responsibilities of the charge nurse include: - Bring the 'crash cart' and the AED. - Designate a qualified person to prepare the resident for transfer by notifying the resident's physician, preparing copies of the MAR, TAR, face sheet, most recent physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Make appropriate calls to summon additional assistance from other floors. - Designate staff as needed to obtain supplies, etc. - Document all aspects of the Code Blue including initiation, notification of MD, family, EMS, and outcome to the resident, etc. in the electronic record. [DATE] - R1 was admitted to the facility status post [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] at 11:32 PM - A progress note by E5 (RN) documented, At approximately 11:00 was called into the room by CNA stating the resident was not responsive. Upon entering the room noted his skin color was gray and ashy, pupils fixed and dilated, chest rise absent. Non-responsive, no carotid pulse, cool to the touch, no breathing for three minutes. Attempted to around (sic) resident via sternal rub. Time of death called at 11:15 PM. Last interaction was at approximately 10:30 PM, patient was anxious about using the urinal and speaking nonsensically. Vital signs taken early in the shift did not show cause for concern. Staff continued to monitor for safety up until the end of shift when CNA called attention to the nurse. Family was notified and is on the way to visit the body. MD was also notified. [DATE] at 11:09 AM - During an interview, E5 (RN) confirmed that she did not check R1's code status and did not perform CPR. E5 stated that after she pronounced R1 (at 11:15 PM), she returned to the nurse's station to notify the Physician and R1's family. E5 stated that when she looked at R1's electronic clinical record, she immediately saw that R1 was a full code. E5 stated that she was asked if she performed CPR during the phone call with E8 (Physician). E5 stated she told E8 that she did not perform CPR. [DATE] at 12:16 PM - During an interview, E6 (LPN) stated that she was sitting in the nurse's station when E7 (CNA) notified E5 that R1 was unresponsive. E6 stated that she responded to R1's room behind E5. E6 stated that she was not familiar with R1. E6 confirmed that she did not think about checking R1's code status and did not bring any equipment (Crash Cart/AED) to R1's room. [DATE] at 12:55 PM - The facility's documented response to R1's incident included: -E2 (DON) was made aware by the 1st floor Unit Manager that R1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility's IDT (interdisciplinary team) met on [DATE] at 3:05 PM to discuss the situation, they determined that this was a reportable incident and began to implement corrective measures. -E2 (DON) met with E5 (RN), the assigned Nurse on duty and Supervisor responsible for the care of R1 at the time of the incident on [DATE] at 3:15 PM. Verbal education and discipline were administered. The ,d+[DATE] Supervisor was assigned to monitor and evaluate the nurse's performance for two weeks and then a follow up meeting was scheduled. -E6 (LPN) received verbal education on Initiating CPR Policy and Practice by E4 (IC/SD) on [DATE]. -A full house audit comparing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive chart review was also conducted on R1. -Beginning on the ,d+[DATE] shift on [DATE], E4 (IC/SD) began educating licensed staff on the CPR policy and procedure, regulations, and facility expectations, specifically to verifying residents code status' upon finding them unresponsive. Live Code Blue Drills were also implemented at the time of education. Education continued around the clock through [DATE], then continued with staff who were not scheduled to work during the initial education period. -An interdisciplinary root cause analysis was conducted on [DATE] at approximately 10 AM. A QA indicator was developed with an auditing form for ongoing monitoring. The Staff Developer/designee will continue to conduct Code Blue drills with licensed nursing staff two times a week for 3 weeks. Once results demonstrate 100% compliance for 3 weeks, then monthly Code Blue drills will be conducted for 3 months or until results are 100% for 3 consecutive months. This plan of correction will be monitored at the quarterly Quality Assurance meeting until substantial compliance has been met. -On the first anticipated orientation class following the incident, scheduled [DATE], the Staff Development Nurse will also provide education on CPR policy and procedure, regulations, and facility expectations specifically to verifying residents code status' upon finding them unresponsive at the new hire and annual orientations. [DATE] at 6:05 PM - Findings were reviewed during an Exit Conference with E1 (NHA), E2 (DON) and E4 (IC/SD). As a result of the facility's corrective measures in response to the incident, with an abatement date of [DATE] that was verified by interviews and review of facility documentation, this deficiency was cited as past non-compliance.

Based on observations, interviews, reviews of facility documentation and resources from national and state public health agencies as indicated, the facility failed to maintain a safe environment by not implementing the appropriate infection control practices as directed by the Centers for Disease Control and Prevention (CDC), the State of Delaware's Division of Public Health (DPH) and the State Health Operations Center (SHOC) during a COVID-19 outbreak in the facility. As a result of the facility's noncompliance, the likelihood of a serious adverse outcome of COVID-19 spreading to additional residents could have occurred if not corrected. The facility was notified of the Immediate Jeopardy (IJ) on Friday, 12/3/21, at 3 PM with an additional finding on Monday, 12/6/21 at 1:35 PM. The IJ was abated on Tuesday, 12/7/2021, at 2 PM. Findings include: Cross refer to F835 1. Earlier this year during the COVID-19 pandemic, the following national and state public health agencies, including the CDC, DPH and SHOC, provided infection control guidance to nursing home facilities as documented below: 4/9/21 (updated) - On the CDC website, the document entitled, COVID-19 Strategies for Optimizing the Supply of N95 Respirators stated, Situational update as of May 2021: The supply and availability of NIOSH-approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices. Check the NIOSH Certified Equipment List to identify all NIOSH-approved respirators. Healthcare facilities should stop purchasing non-NIOSH approved respirators for use as respiratory protection and consider using any that have been stored for source control where respiratory protection is not needed . Healthcare facilities should return to using only NIOSH-approved respirators where needed . It is important that HCP (Healthcare Personnel) be trained on indications for use and the proper use of N95 respirators. The OSHA Respiratory Protection standard requires employers to provide respirator training to an employee prior to use in the workplace . Proper use of respirators, including putting on and removing them, limitations on their use, and maintenance, is essential for effective use of respiratory protection. HCP should be thoroughly trained before they are fit tested to ensure they are comfortable donning (putting on) the respirator and know how to conduct a user seal check. HCP should be trained on the respirator they are expecting to use at work . Personal Protective Equipment: Respiratory Protection . Proper use of respiratory protection by HCP requires a comprehensive program (including medical clearance, training, and fit testing) that complies with OSHA's Respiratory Protection Standard and a high level of HCP involvement and commitment. The program should also include provisions for the cleaning, disinfecting, inspection, repair, and storage of respirators used by HCP on the job according to manufacturer's instructions . (https://www.cdc.gov) 4/20/21 - According to the SHOC Call Minutes, the following information was documented and emailed to all healthcare facilities: Core Principles of COVID-19 Infection Prevention: . Appropriate staff use of Personal Protective Equipment (PPE); Effective cohorting of residents (e.g. separate areas dedicated to COVID-19 care) . The DHCQ Medical Director (S4) addressed the following on the conference call: . The CDC came up with this guidance because N95's are much more available . the standard is used for both red & yellow zones. We want to make sure you all understand what the minimal standards are . With new guidance coming in, the CDC is saying when you know someone is at a significant risk of COVID, staff workers should be utilizing N95 masks . I encourage you to look up the CDC guidance . 5/28/21 (last update) - On the Delaware Coronavirus website, the DPH document entitled Cohorting Plan for Long Term Care Facilities, stated, . The most effective way to prevent spread of COVID-19 in congregate settings is to create 'zones' of similarly dispositioned patients by cohorting them in physically designated areas . Cohorting is most effective . when there are dedicated staff and equipment for each cohort . Red (COVID-19 Positive/Isolation) Zone . Healthcare workers should wear full personal protective equipment (PPE) (gloves, gown, N-95 mask and eye protection) when taking care of these patients . the priority is that the Red Zone have a separate breakroom for staff . (https://coronavirus.delaware.gov) Undated - According to the Delaware Coronavirus website, a DPH document entitled, Staff PPE for Different Zones outlined the required PPE in the Red Zone (COVID positive on Transmission Based Precautions): Gown, Gloves, Surgical Mask, Face shield/eye protection and N-95 Mask Required**** . ***During an outbreak Green zones should also be in Gowns/gloves/mask unless unit is discrete, and staff are dedicated to the unit. ****Refer to CDC guidance: Strategies for Optimizing the Supply of N95 Respirators. Observations revealed the following: 12/1/21 from 10:30 AM to 11:20 AM - Observations of the three resident floors revealed that all staff were wearing face masks. Outside of the COVID-19 unit on the first floor, which was separated by a plastic barrier, a box of disposable KN95 face masks were observed sitting on top of the isolation cart for staff to use. 12/1/21 - The facility's COVID-19 line listing revealed that three residents (R2, R31 and R62) tested positive for COVID-19 and were in the COVID-19 unit, rooms 106, 107 and 108. 12/1/21 - The facility's staffing assignments on the 7 AM - 3 PM shift revealed that E23 (RN) and E20 (CNA) were assigned to provide direct care to both COVID-19 positive residents and COVID negative residents. 12/3/21 at 10 AM - An observation on the first floor in the hallway where the COVID-19 unit was located revealed E20 (CNA) entering the COVID-19 unit through the zippered plastic barrier wearing only a surgical face mask. E10 (RNAC) was immediately informed of the observation as she was the closest staff person in the hallway at the time. At 10:05 AM, E1 (NHA) and E4 (ICP) were walking towards the COVID-19 unit and were notified of the observation. At 10:25 AM, E4 (ICP), E21 (Staff Educator) and the Surveyor (S1) observed E20 (CNA) exit from the COVID-19 unit through the plastic barrier wearing a surgical mask and carrying a clear plastic bag containing linen from the COVID-19 unit down the hallway to the opposite end to dispose of the bag of linen in the soiled utility room. The facility failed to ensure that staff were wearing appropriate PPE in the COVID-19 unit; that the COVID-19 unit was separate, distinct and discrete; and the COVID-19 unit had a separate receptacle for soiled linen located within the unit itself. 12/3/21 at 10:31 AM - During an interview in the presence of E4 (ICP) and E21 (Staff Educator), E20 (CNA) confirmed that she was assigned to provide direct care to both COVID-19 positive residents and COVID negative residents. When E20 was asked if she wore a N95 mask in the COVID-19 unit, E20 stated, No, it was too heavy. E20 confirmed that she wore a surgical mask when she provided direct care to a COVID positive resident. E20 stated that she removed her PPE after leaving the resident's room, changed her surgical mask and hand sanitized. 12/3/21 at 12:25 PM - During discussion with the State Agency, it was determined that the facility was not following guidance from the CDC and DPH with respect to the COVID-19 outbreak. The DPH guidance for COVID-19 outbreaks located on the Delaware Coronavirus website stated that unless the COVID-19 unit was discrete and staff were dedicated to the unit, the facility's staff should also be in gowns, gloves and masks in the Green zones where non-COVID residents reside. [Face shield/eye protection was not required, but to strongly consider if the community positivity rates are in yellow or red.] The facility did not have a separate, distinct and discrete COVID-19 unit, which included and was not limited to, dedicated staff, a separate entrance/exit for staff with screening procedures for dedicated staff upon entrance, and a separate breakroom and bathroom for dedicated staff. The facility failed to have neither infection control practice in place during a COVID-19 outbreak from the first day of the survey on 12/1/21. 12/3/21 at 1:15 PM - During a follow-up interview by S2 and S3 (Surveyors), E20 (CNA) stated that she was assigned to the COVID-19 positive residents in rooms 106, 107 and 108. E20 was observed wearing a surgical mask as she was walking around the first floor nurse's station, two and a half hours after providing direct care to a COVID-19 positive resident while wearing a surgical mask, and not the required N95 face mask. According to E20's Time Card Report on 12/3/21, E20 worked the entire day shift from 6:59 AM to 3:31 PM. 12/3/21 at 1:20 PM - During an interview by S2 and S3 (Surveyors), E22 (AA) stated that she was assigned to provide activities to all of the residents on the first floor, including the COVID-19 positive residents in rooms 106, 107 and 108. E22 was observed wearing a KN95 mask during the interview. E22 stated that before entering the closed off COVID-19 area, she would apply gloves, a gown, a KN95 mask and eye protection. Before she leaves the closed off area, she would remove all PPE, sanitize her hands upon exit and don a new KN95 mask. 12/3/21 at 1:27 PM - During an interview by S2 and S3 (Surveyors), E13 (LPN) stated that she was assigned to residents from rooms 101 through 115, which included the COVID-19 positive residents in rooms 106, 107 and 108. E13 was observed wearing a KN95 mask during the interview. E13 stated that before entering the closed off COVID-19 area, she would apply gloves, a gown, a KN95 and eye protection. Before she leaves the closed off area, she would remove all PPE, sanitize her hands upon exit and don a new KN95 mask. 12/3/21 at 3:03 PM - The survey team met with E1 (NHA), E2 (DON) and E4 (ICP). The facility was notified of an Immediate Jeopardy due to lack of implementing appropriate infection control practices during a COVID-19 outbreak. 12/3/21 at 5:22 PM - The facility's IJ abatement plan included: -At 4 PM, education sessions of staff were initiated and covered the PPE required in the Red Zone (COVID unit), the utilization of designated staff in the COVID-19 unit, including the use of a separate entrance/exit and a designated staff breakroom in the COVID unit, including a bathroom. The designated staff will be educated that they are not to go into any non-COVID areas of the facility, entering and exiting through the designated entrance only. -At 5 PM, the facility placed Red Zone signage to the COVID-19 unit; -At 5 PM, the facility immediately designated staff to the COVID-19 unit. The COVID-19 unit was redesigned to include a separate entrance and exit, an empty room to be utilized as the designated staff break area which includes bathroom; and -At 5 PM, the facility supplied N95 masks for use on the COVID-19 unit. 12/3/21 at 5:35 PM - S1 and S2 (Surveyors) with E2 (DON) observed the separate, distinct and discrete COVID-19 unit. E24 (LPN) was designated to provide all of the direct care to the COVID-19 positive residents. 12/6/21 at 8:57 AM - An observation through the window on the entrance/exit door to the COVID-19 unit revealed that E24 had her own personal respirator. 12/6/21 at 9:30 AM - During an interview, E1 (NHA) was asked to provide more information on E24's (LPN) personal face mask being worn in the COVID-19 unit. In response, E2 (DON) provided E24's personal face mask information: Advantage 200LS Respirator Facepiece # 8. 12/6/21 from 12:00 PM to 1:15 PM - Multiple interviews conducted with direct floor staff revealed: -E13 (LPN) was observed wearing an N95, however, it was not fitted as there was an opening below her chin. E13 confirmed that she had not been trained nor fit-tested for the N95. E13 stated that she was told to wear them in the COVID-19 unit. -E16 (LPN) stated that the facility provided KN95's and surgical blue masks. E16 confirmed that she had not been trained nor fit-tested for the N95. -E28 (Housekeeping) stated that she has never been fitted for the N95. -E29 (CNA) stated that she received an in-service to wear a N95 around the COVID-19 positive residents. However, she was not aware of the fit-testing requirement. -E30 (CNA) was observed wearing an N95, however, she had not received any N95 training or been fit tested . -E31 (LPN) stated that he had not received any N95 training or been fit tested . -E32 (CNA) stated that she was not aware of the fit testing requirement for N95. -E24 (LPN) stated that she was fit tested with her personal mask, Advantage 200LS Respirator, at her other job about four months ago. She stated that she was requested to remove her personal mask and wear a facility-provided N95. E24 confirmed that she had not received any N95 training or been fit tested in the facility. 12/6/21 at 1:30 PM - During an interview, E4 (ICP) confirmed that the facility was following CDC guidance for infection control prevention. E4 also confirmed that the facility had not provided training and fit testing of N95's for the staff. 12/6/21 at 1:35 PM - During an interview, E1 (NHA) and E4 (ICP) were informed that an additional finding was added to the Immediate Jeopardy and the facility's abatement plan will need to address the lack of training and fit-testing of N95s for staff. 12/6/21 at 3:34 PM - The facility amended their Immediate Jeopardy Abatement Plan to include: . At 2 PM, the facility's Infection Control Consultant was contacted to discuss a plan to get all staff trained and fit-tested on the appropriate type of N95 required to be worn when providing direct care to a COVID-19 positive resident . will be sending the contact information of fit testing resources by the close of business on 12/6/2021. Upon receipt of the contact information, arrangement will be made for the Fit testing trainer to come onsite as soon as possible. All staff will be fit tested and educated within seven business days. 12/7/21 at 2 PM - The facility's revised Immediate Jeopardy Abatement Plan with documented evidence addressing the lack of training and fit-testing on the appropriate type of N95 required to be worn when providing direct care to COVID-19 positive residents included the following: . On 12/6/2021, at approximately 1400 (2 PM), . (the facility's) Infection Control Consultant was contacted to discuss a plan to get all staff trained and fit tested . (Company name) will be on site at Kentmere 12/7/2021 to begin to fit test some of Kentmere staff. (Company name) will also be on site at Kentmere on 12/9/2021 at 11:00am through 5:00pm and 12/10/2021 at 6:00am through 2:00pm to Fit Test Kentmere employees. They will also be Training the Trainer of Kentmere staff to ensure that any staff not Fit tested by them and future new hire staff, can be Fit tested . To correct the immediacy of the situation, on 12/6/2021 at 1630 (4:30 PM) Kentmere ensured there was a fit tested nursing staff member on schedule throughout the 3-11 and 11-7 shift to care for the COVID-19 positive resident. A Fit Tester, (name), came into the facility on [DATE] and Fit tested (E33, RN) at approximately 1730 (5:30 PM). (E33), RN worked the 3-11 and 11-7 shift on 12/7/2021. On 12/7/2021, (company name) was on site and fit tested 7 Kentmere employees. The employees Fit tested on [DATE] include: E4 (ICP), E2 (DON), E3 (ADON), E13 (LPN), E15 (RN, UM), E10 (RNAC), E21 (Staff Educator). Until all staff are Fit tested , Kentmere will ensure that a staff member that is Fit tested is on shift to care for any future COVID-19 positive resident. 2. An observation on 12/1/21 at 1:18 PM, during a COVID-19 outbreak in the facility, revealed three (R42, R69 and R301) residents sitting close together (within 6 feet) in the second floor TV lounge. All three residents were not wearing face masks. R42 and R301 were talking to each other, while R69 was sleeping in between them. Finding was immediately confirmed with E19 (LPN). 12/9/21 at 10:48 AM - Finding was reviewed with E1 (NHA), E2 (DON) and E4 (ICP). The facility failed to ensure that source control, specifically maintaining physical distance, was followed as part of their infection prevention and control program. 12/9/21 at 1 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E4 (ICP).

Based on record review, interview, review of hospital records and other facility documents as indicated, it was determined that the facility failed to ensure that the resident received adequate supervision to prevent accidents for one (R47) out of three sampled residents for fall investigations. For R47, the facility failed to ensure adequate supervision by failing to ensure close monitoring/supervision of R47, a resident with dementia, poor safety awareness, a history of multiple falls, and attempting to stand up without assistance. This deficient practice resulted in harm to R47 when she was left unattended, not monitored and not supervised and fell in the common area of the unit. R47 required emergent transfer to the hospital where it was confirmed that she sustained a new L1 compression fracture and a right T10 [MEDICATION(S)] process fracture. Findings include: The facility's policy titled Fall Prevention & Management Guidelines, dated June 2016, stated: .8. The Interdisciplinary Team will review the fall and will complete the following documentation: - Obtain physician's orders as needed. - Update Care Plans as needed. - Update CNA flow records as needed. - The DON/designee will complete the DON Post Fall Follow-up. 9. The Unit Manager is responsible for initiating recommendations and communicating them to the staff. 10. Interventions will be periodically re-evaluated to determine the continued need as well as effectiveness. Changes will be made as Interdisciplinary Team determines them appropriate. The facility's In-Service Attendance Sheet, dated 1/25/19, for the topic title of 1:1 or 1:2 Supervision, Broda Chair Requirements, presented by E23 (ADON), stated, .1:1 or 1:2 Supervision, staff member within arm reach at all times, Do not leave resident alone, notify nurse or another CNA, follow provided list if time is not adequate notify nurse . Broda Chair, used for fall risk, do not lock the chair . 1. Review of R47's medical record revealed the following: 4/22/18 - R47 was admitted to the facility with diagnoses that included pelvic fracture secondary to a fall, dementia, high blood pressure, and [CONDITION(S)]. 4/22/18 (Original date) - A care plan was initiated for falls due to a history of falls and an unsteady gait. The care plan interventions included to analyze any resident falls that may occur to determine whether a pattern or trend can be addressed; appropriate footwear non-skid shoes or slippers when out of bed; fall mats on sides of bed when resident in bed and remove when resident is out of bed; 1:2 supervision; encourage resident to participate in the Restorative Nursing Program's walking program when restless; and Broda chair when out of bed. 4/11/19 - The attending physician's history and physical documented diagnoses including high blood pressure, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)] joint disease. 7/31/19 - A physician's order was obtained from E7 (MD) for 1:2 supervision when out of bed. 8/7/19 - A significant change MDS assessment stated R47's daily decision making skills were severely impaired, she required limited assistance of one staff for transfers and toilet use, and did not walk in her room or the corridor. The MDS stated R5's balance while moving from a seated to standing position, walking, and transfers between bed and chair or wheelchair were not steady, and was able to only with staff assistance. R47 experienced one fall with a non-major injury. 10/17/19 1:00 PM - The facility's Incident/Accident Report stated that R47 had an unwitnessed fall, staff heard a thump and turned around to see R47 sitting on the floor, in front of the Broda chair with no injury. Witness statements from all nursing staff assigned to the 7:00 AM to 3:00 PM shift [(E9 (RN), E11 (CNA), E12 (CNA), and E13 (CNA)] documented that nursing staff did not observe the fall. All four employees documented that the contributing factor was R47 trying to get up to walk or perform a transfer. The assigned CNA, E11's statement documented that she was away from the area when R47 fell . 10/18/19 2:41 PM - The Occupational Therapy Treatment Encounter Note, by E17 (OTR/L) documented that R47 was referred to OT following a fall. The note documented, .pt. (patient) does not remember the fall, pt. has behavior of attempting to stand, pt. is assist of 1. pt. now on 1:1. Staff educated on activities appropriate for pt.'s cognitive level . 10/18/19 6:30 PM - The facility's Incident/Accident Report stated that R47 had an unwitnessed fall in the common area of the unit. R47 was found laying on her side and upon assessment had no apparent injury and was placed back into the Broda chair. Approximately two hours after the fall, R47 complained of back pain and an order was obtained to transfer R47 to the hospital. Witness statements from all nursing staff assigned to the 3:00 PM to 11:00 PM shift [(E14 (LPN), E15 (CNA), and E16 (CNA)] documented that nursing staff did not observe the fall. All three employees documented the contributing factor was that R47 was left unsupervised. In addition, to prevent further unwitnessed falls, 1:1 supervision was to be implemented. 10/18/19 - R5 was treated in the emergency room . Review of the hospital record revealed that R47 sustained a new L1 compression fracture. 10/18/19 10:00 PM - R47 returned to the facility with an order for [MEDICATION(S)] as needed for severe pain. 1/14/2020 10:41 AM - An interview with E10 (RN, UM) was conducted. E10 confirmed that after the 10/17/19 fall, no new interventions and/or revisions of interventions to prevent further falls and injury were completed. E10 verbalized that a post fall assessment by the therapy department was completed following the fall on 10/17/19, however, there were no changes in interventions. E10 confirmed that R47 had an order for 1:2 supervision when out of bed and stated this would have been communicated to the assigned CNA during the shift change. 1/14/2020 3:30 PM - An interview with E14 (LPN) revealed that, at approximately 6:30 PM, R47 was in the common area and E14 verbally instructed E15 (CNA) to Keep an eye on her due to R47's high risk for falls as E14 would be starting medication administration and would not be in the common area to supervise R47. E14 stated that she was not notified when E15 left the common area and left R47 unsupervised. E14 verbalized that the fall was unwitnessed, as E15 and E16 (CNA) were not in the common area and were placing other residents to bed. After the fall, R47 was placed back in the Broda chair in the common area and approximately 2 hours afterwards, R47 started grimacing, thus E14 (LPN) contacted E7 (MD) and an order was obtained to transfer R47 to the hospital. 1/15/2020 10:40 AM - An interview with E17 (OTR/L) revealed that she completed a post fall assessment following the 10/17/19 fall. R47's functional status remained unchanged and R47 continued to require assistance of one staff for transfers. E17 verbalized that the 1:1 supervision was a new intervention, as R47 was at high risk for additional falls following the 10/17/19 fall. E17 verbalized that she educated the nursing staff following the post fall evaluation on activities for R47. 1/15/2020 1:45 PM - An interview with E2 (DON) revealed that R47 had a history of impulsiveness, including standing up without assistance and poor safety awareness, which resulted in multiple falls in the facility. E2 stated that on 7/31/19, an intervention of 1:2 supervision was ordered and implemented as an intervention for prevention of falls and injury. E2 verbalized for the 10/17/19 fall, E9 (RN) was changing the channel on the TV and had her back towards R47, heard a thump and observed R47 on the floor. The surveyor provided a copy of the OT Note, dated 10/18/19, which documented 1:1 supervision, however, E2 verbalized that she was not aware of this note until it was provided by the surveyor. E2 verbalized that there were no changes in interventions after the 10/17/19 fall. E2 confirmed the ordered 1:2 supervision was not implemented when R47 fell on [DATE] at 6:30 PM. In addition, E2 confirmed that 1:1 supervision was not in place when E47 fell on [DATE]. 1/16/2020 10:57 AM - An interview with E7 (MD) revealed that R47 had [CONDITION(S)] and [CONDITION(S)] and E7 could not rule out that the new L1 compression fracture was caused by the fall on 10/18/20 when R47 had a new onset of pain. 1/21/2020 11:30 AM - Findings were reviewed with E1 (NHA) and E2 (DON). E1 verbalized that E7 (MD) stated that the L1 compression fracture could have happened without the fall. The surveyor replied that during an interview with E7, E7 verbalized that she could not rule out that the fall resulted in the fracture. E1 and E2 verbalized that they were not able to provide evidence of 1:2 supervision for R47, thus, following the 10/18/19 fall, the order was discontinued.

Based on interviews, review of the clinical record, hospital record, facility and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility failed to develop and implement an abuse policy and procedure that addressed the requirements of the Federal Regulation §483.12(b). Specifically under the Protection requirement, the facility failed to have written procedures that ensured that all residents are protected from physical and psychosocial harm during and after the investigation. This must include: Responding immediately to protect the alleged victim and integrity of the investigation . The facility failed to protect R45 (alleged victim) and all residents when: - The allegation of sexual abuse was made on 11/7/18 and the facility began an investigation by obtaining written statements of those staff involved. However, the facility failed to immediately protect R45 as E7 (accused nurse) returned to R45's floor before leaving the facility on 11/7/18; and - The facility failed to protect all residents, including R45, when an investigation by law enforcement started on 11/21/18 and was ongoing as of 12/6/18 regarding the 11/7/18 allegation of sexual abuse against E7, a facility nurse. E7 remained on duty during the ongoing investigation, which allowed the accused nurse to have access to all residents, including R45. An immediate jeopardy situation was identified on 12/6/18 at 1:32 PM. Findings include: Cross refer to F580, F608, F609 and F610 The facility's policy entitled, Abuse, Neglect, Mistreatment, Misappropriation and Exploitation, effective (MONTH) (YEAR), stated, .Procedures: .5. Staff Responsibilities .b. If an act of abuse .is witnessed, the witness must act to first remove the source of the act, whether it is a staff member or a visitor, and then take steps to protect the resident . The facility failed to have written procedures as per the Federal Regulation requirement to ensure protection of all residents/alleged victim during and after the investigation. Review of R45's clinical record revealed: 10/2/18 - Review of a quarterly MDS assessment stated that R45 was severely cognitively impaired and had active [DIAGNOSES REDACTED]. 11/7/18 at 6:45 AM - An allegation of sexual abuse involving E7 (accused nurse) and a resident, R45, was reported by E10 (CNA) to E9 (RN, House Supervisor). E9 reported the allegation to E2 (DON), then E9 and E2 reported the allegation to E1 (NHA). E7 was requested to leave the floor to meet with E1 (NHA) and E2 (DON) on the ground floor where the facility management offices are located. E7 was then requested to write a statement. Once the allegation was made and facility's investigation started by obtaining written statements of those staff involved, the facility failed to protect R45 as E7 was allowed to return to R45's floor before leaving the facility on 11/7/18. The following events occurred after facility management was made aware and started their investigation: - At 8:07 AM, E7 documented a nurse's note in R45's electronic clinical record; - At 8:21 AM, E7 exited R45's floor according to E7's electronic swipe Card Activity History Report; - At 8:22 AM, E7 exited the facility. 11/8/18 at 10:04 AM - According to the facility's Incident Report submitted to the Delaware's Office of Long Term Care Resident Protection, the facility stated, .An internal investigation was conducted and completed and the allegation was found unsubstantiated. 11/8/18 between 9:45 AM-10:04 AM - F6 (R45's POA) stated, during a follow-up interview on 12/12/18 at 11:24 AM, that she asked if the facility called the local law enforcement agency to report the allegation of sexual abuse. It was not until after F1 (R45's family member) arrived at the facility at approx. 11:30 AM, met with E1 (NHA) and E2 (DON), F1 called F6 with an update, and it was at this point when R45's family (F1 and F6) insisted on a police report. 11/8/18 at 1:49 PM - According to the local law enforcement agency's dispatch records, the police were called at 1:49 PM. A police officer, F3, responded to the facility and met with E1 (NHA) and E2 (DON), whom informed F3 about the allegation and the facility's internal investigation findings, which were unsubstantiated. F3 left the facility without writing a report at 2:04 PM. 11/9/18 at 1 PM - A late entry nurse's note documented on 11/12/18 at 11:19 AM by E2 (DON) stated, After discussion with IDT, decided to send resident (R45) to ED for comprehensive exam .(F2, family member) called and in agreement with decision . 11/9/18 at 5:48 PM - According to the hospital record, R45 was seen and examined by the Emergency Department's Forensic Team. F4 (hospital Forensic Nurse) notified the local law enforcement agency and the State Survey Agency (at 5:53 PM) that R45 was seen and examined for an alleged sexual assault of adult. 11/21/18 at approx. 1 PM - According to email correspondence between F5 (Detective with the local law enforcement agency's Criminal Investigations Division) and E1 (NHA) and E2 (DON), F5 met with E1 and E2 at the facility about the 11/7/18 allegation of sexual abuse of R45. The facility provided F5 with requested facility documents, names and contact information for facility staff involved. The facility became aware that the 11/7/18 allegation of sexual abuse involving R45 and E7 (accused nurse) was being investigated by the local law enforcement agency's Criminal Investigations Division. 11/21/18 through 12/6/18 - The facility moved E7 (accused nurse) to a different floor from R45 after the 11/7/18 incident. Review of E7's Time Card Report revealed the accused nurse worked the following 11 PM to 7 AM shifts: - Friday, 11/23/18, into Saturday, 11/24/18; - Saturday, 11/24/18, into Sunday, 11/25/18; - Sunday, 11/25/18, into Monday, 11/26/18; - Monday, 11/26/18, into Tuesday, 11/27/18; - Friday, 11/30/18, into Saturday, 12/1/18; - Saturday, 12/1/18, into Sunday, 12/2/18; - Sunday, 12/2/18, into Monday, 12/3/18; and - Monday, 12/3/18, into Tuesday, 12/4/18. 11/21/18 through 12/6/18 - Review of the facility's staff posting revealed that E7 (accused nurse) worked as a floor nurse in addition to being the facility's House Supervisor on the following 11 PM to 7 AM shifts: - Saturday, 11/24/18, into Sunday, 11/25/18; - Friday, 11/30/18, into Saturday, 12/1/18; and - Saturday, 12/1/18, into Sunday, 12/2/18. Review of the facility's Nurse Supervisor policy, effective 5/16, stated, .Policy: To outline the duties and responsibilities of the Nurse Supervisor in compliance with State regulatory procedures .1. In compliance with State regulation, 2 hours of Registered Nurse (RN) time each shift (7-3, 3-11, 11-7), will be dedicated to administrative functions which include: - Rounds on units - Assisting with coverage/scheduling issues - Family concerns - Problem solving . 11/21/18 through 12/6/18 - Review of the facility's electronic swipe Card Activity History Report, which captured E7's assigned card access/exit to the floor where R45 was located, revealed the following dates and times: - 12/2/18 at 1:36 AM; - 12/2/18 at 2:20 AM; - 12/2/18 at 2:23 AM; - 12/2/18 at 6:44 AM; - 12/2/18 at 7:18 AM; - 12/3/18 at 6:52 AM. The facility became aware on 11/21/18 that the local law enforcement agency's Criminal Investigations Unit was investigating the 11/7/18 allegation of sexual abuse of R45 by E7. The facility failed to protect all the residents, including R45, during the investigation by allowing E7 to remain on duty, including assigning E7 as House Supervisor for 3 out of 8 shifts, giving E7 access to all residents, including R45, from 11/21/18 to 12/6/18. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that during the facility's investigation, the staffing schedule was checked to see if E7 (accused nurse) was off and E7 was. E1 stated otherwise, we would have had to suspend E7 or asked E7 not to come in until the facility finished their investigation. E7 was not scheduled to work until Saturday night, 11/10/18, on 11PM to 7AM shift. E1 stated that F5 (Detective from Criminal Investigations Unit) met with her and E2 (DON) and that F5 would notify her of the outcome of their investigation. E1 stated that she spoke with F6 (R45's POA) about not having E7 care for R45 and F6 agreed. E1 stated that E7 was assigned to a different floor from R45. E1 was asked by this surveyor if E7 had been House Supervisor on the 11PM-7AM shifts since the 11/7/18 incident, E1 said yes. 12/6/18 at 1:23 PM - E1 (NHA) and E2 (DON) was informed of an Immediate Jeopardy. 12/6/18 at 8:15 PM - The Immediate Jeopardy was abated. E1 (NHA) stated that R7 was placed on Administrative Leave until the conclusion of the criminal investigation.

Based on record reviews, interviews and review of other facility documentation as indicated, the facility failed to ensure that the residents' code status (advanced directives) listed on the individually printed Resident Face Sheets, kept in binders in the ground floor reception area and the second floor nurses station, matched the electronic medical record (physician orders [REDACTED]. For 6 (R7, R20, R54, R73, R83, and R96) out of 97 sampled residents, the Resident Face Sheets were inconsistent with the electronic medical records (EMR). For 2 residents (R54 and R96), their electronic medical documents failed to match the Emergency Face Sheets binder located in the ground floor reception area. For 4 residents (R7, R20, R73, and R83), their EMR's failed to match the 2nd Floor Face Sheets binder located in the second floor nurses station. The facility no longer uses charts. Furthermore, interviews with multiple staff revealed inconsistencies regarding where to find the backup information on each resident's code status in the event of an EMR system failure. The facility failed to have a system in place for staff to obtain the residents' accurate code status in the event of an EMR system failure which placed these residents in an immediate jeopardy situation. The IJ was identified on [DATE] at 10:55 AM and was abated on [DATE] at 3:30 PM. Findings include: The facility's Advance Directives policy (undated) stated, Every resident has the right to accept or refuse medical care. Advance Directives communicate your choices of care in the event that you become physically or mentally unable to communicate yourself . specific types of Advance Directives include: 1. Do Not Resuscitate (DNR) which means that if a resident is found not breathing or non-responsive, measures would not be taken to try to start the heart pumping again. 2. Cardio-Pulmonary resuscitation (CPR) is the act of applying force to the chest with the hand, compressing the heart, and breathing into the resident's mouth, filling the lungs with air in an attempt to restart the heart beating again. The facility's Consent Form Code Status policy (undated) stated, At some point . a catastrophic event may occur (for example, the resident's heart or breathing may stop). At that point, the question of whether to begin extraordinary measures to attempt resuscitation arises (for example, cardiopulmonary resuscitation (CPR) attempts, electric shock potentially leading to chest surgery, artificial breathing machines .) Without written instructions to the contrary, these invasive procedures must be attempted . some residents decide either independently or through their substitute Decision maker that they do not wish for resuscitation measures in cases of heart or breathing failure. In those cases the doctor will write a DO NOT RESUSCITATE or 'DNR' order. Once that order is written, no measures will be taken to restart the heart or respirations (no CPR or mechanical ventilation . 1. Review of R7's clinical record revealed: During the initial pool record review, a code status form (scanned into the EMR), dated [DATE], stated that R7 was a no code or DNR and there was a current physician order [REDACTED]. The emergency book in the reception area listed R7's code status as DNR. R7 resided on the 2nd floor. In contrast to the code status form, physician order [REDACTED]. 2. Review of R20's clinical record revealed: During the initial pool record review, a code status form, dated [DATE], stated that R20 was a DNR and there was a current physician order [REDACTED]. The emergency book in the reception area listed R20's code status as DNR. R20 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. The remainder of resident's were identified when code status' were checked for all residents that did not have record reviews during the initial pool. 3. Review of R73's clinical record revealed: Review of R73's code status form, dated [DATE], stated that R73 was a DNR and there was a physician order, dated [DATE], for DNR in the EMR. The emergency book in the reception area listed R73's code status as DNR. R73 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. 4. Review of R83's clinical record revealed: Review of R83's code status form, dated [DATE], stated that R83 was a full code and there was a current physician order, dated [DATE] for full code in the EMR. The emergency book in the reception area listed R73's code status as full code. R83 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. 5. Review of R54's clinical record revealed: Review of R54's code status form, dated [DATE], stated that R54 was a no code or DNR. There was a current physician order [REDACTED]. R54 resided on the 3rd floor of the facility. In contrast to the code status form and the physician's orders [REDACTED]. 6. Review of R96's clinical record revealed: Review of R96's code status form, dated [DATE], stated that R96 was a no code or DNR. There was a current physician order [REDACTED]. The 2nd floor face sheet binder listed R96's code status as DNR. R96 resided on the 2nd floor. In contrast to the code status form and the physician's orders [REDACTED]. [DATE] 9:16 AM - E2 (DON) was interviewed on the 2nd floor. E2 stated that resident code status was in the EMR. When asked how staff would obtain a resident's code status if the EMR was down, E2 stated staff would call the ground floor receptionist office where a book was kept with everyone's face sheet and code status. E2 stated there was someone in the reception area 24 hours a day. E2 stated there was not a code book on the 2nd floor. [DATE] 9:50 AM - E20 (reception clerk) was interviewed. E20 stated that someone was at the reception desk from 8 AM to 8 PM, however, the office was not locked when there was no one at the desk. [DATE] 11:45 AM - E13 (LPN on 2nd floor) was interviewed. When E13 was asked how she would obtain a resident's code status if the EMR was down, E13 stated that when the receptionist was there, she'd call the receptionist (on the ground floor) to obtain a resident's code status (have binder of all resident's face sheets listing code status' in the receptionist office). E13 stated on night shift, staff use the 2nd floor Face Sheets binder that's kept in the 2nd floor nurses station. The emergency book in the reception area contained face sheets for each resident. [DATE] 4:47 PM - E19 (LPN) was interviewed on the third floor. When asked how she would obtain a resident's code status if the EMR was down, E19 stated she would ask someone who was familiar with the resident for the code status. E19 stated there was no code status binder on the third floor. [DATE] 10:55 AM - Findings were reviewed with E1 (NHA) and E2 (DON) and they were advised that an IJ was identified when 6 current residents were found to have inconsistent advance directives related to their code status'. [DATE] 3:15 PM - Review of the 2nd floor binder and the Emergency book at the receptionist office verified that the incorrect code status' for the 6 residents were corrected. Additionally, the survey team interviewed 2 nurses from the ,[DATE] shift for each floor and confirmed they were aware of where and how to obtain current code status' for residents. [DATE] 3:30 PM - At this time, we also received an approved plan of correction that included: correction of code status' on identified residents after a whole facility audit of consent forms, orders and face sheets, the facility policy on code status was updated, all new residents and residents with code status changes are to be discussed at High Risk Meetings Monday- Fridays, in-services are to be done including: use of Unit Book/Front office book to verify code status in event of power outage, on hire, a competency verification regarding code status and contingency plan will include nurses, activity, admissions, social service and rehabilitation staff, and annual training will be updated to include review of the policy and process. Additionally, shift report will include communication related to new and/or changes in code status and monitoring will be done on the above measures. The IJ was abated at this time. The facility failed to maintain consistent documentation of residents' code status leading to the possibility that the incorrect code status could be implemented during an emergency event resulting in immediate jeopardy to the residents.

Based on record review, observations, and review of other facility documentation as indicated, it was determined that for 2 (R31 and R52) out of 54 sampled residents, the facility failed to ensure that residents were free from abuse. For R31, the facility failed to ensure R31 was free from potential physical, emotional and verbal abuse and for R52, the facility failed to ensure R52 was free from actual physical, emotional and verbal abuse from resident to resident altercations. For R31, another resident in the same hallway (R15), has wandered into R31's room during the night which has the potential for abuse. R52, who resides in the same hall as R31 and R15, has been emotionally, verbally and physically abused by R15 as evidenced by cursing, yelling, hurtful remarks, hitting, and being accused of things. As a result of this abuse, R52 has experienced feeling fearful, upset, sad, anxious, and at times, R52 isolates herself in her room to avoid R15. This is a harm level deficiency for R52. Findings include: Review of the facility policy entitled Abuse, Neglect, Mistreatment, Misappropriation, and Exploitation, effective (MONTH) (YEAR), stated, . Purpose: To ensure that all patients and residents will be free from abuse, neglect, mistreatment, misappropriation and exploitation of funds and resources . a. Physical abuse by unnecessarily inflicting pain or injury to a patient or resident. This includes but is not limited to, hitting, kicking, punching, slapping, pulling hair, or corporal punishment of any kind . c. Emotional Abuse which includes, but is not limited to, ridiculing, demeaning, humiliating, or cursing at a patient or resident , or threatening a patient or resident with physical harm Staff Responsibilities . b. If an act of abuse, neglect, mistreatment or property misappropriation is witnessed, the witness must act to first remove the source of the act, whether it is a staff member or a visitor, and then take steps to protect the resident . 1. Review of R52's clinical record revealed the following: R52 was admitted to the facility in (YEAR). A quarterly MDS assessment, dated 10/4/18, coded R52 on a scale of 0-15, with 0 being never/rarely made decisions and 15 being the highest level of cognition (decisions consistent/reasonable), as a 15. Review of an incident report for R52, dated 11/25/18 and timed 3:30 PM, stated, Resident involved in incident with another Resident (R15) in which she was slapped on right arm . Resident (R15) noted verbally aggressive/physically aggressive towards another Resident (R52). The incident occurred in the lounge near the nurses station. Review of a CNA statement on 11/25/18 and timed 3:30 PM, stated, I witnessed (R15) come out of her room yelling at (R52). I walked over as she (R15) was hitting (R52) (she (R15) smacked her (R52) on her arm once). A progress note, dated 11/25/18 and timed 5:05 PM, was written for R15 (the resident involved in the incident) and it was included in the incident report. The progress note, written by a nurse, stated, At approx. (approximately) 1530 (3:30 PM), resident (R15) noted standing in lounge area, agitated while shouting 'you stole my money' headed towards another resident (R52). CNA approached (R15) and (sic) a very calm therapeutic manner, however resident continued to be verbally aggressive (towards other resident) and quickly slapped the resident's left (sic) arm. Attempts to redirect made, resident (R15) escorted to her room . remains A&OX1 (alert to person only, not to place or time); to self, per established baseline. Nursing staff to monitor . A progress note, dated 11/25/18 and timed 5:05 PM, stated, At approximately 1530 (3:30 PM) (R52) was involved in an incident with another resident (R15). Another resident became verbally aggressive towards (R52), and quickly slapped her on the right arm. (R52) was removed from scene immediately, and assessed by Nurse . Resident stated, 'I don't know why she did that', when asked if she knew anything that could have contributed to the incident . There was no obvious injury to R52's arm. R52 was interviewed by the state surveyor on 11/28/18 at 9:15 AM. R52 expressed that R15, who resides down the hall a few doors from her room curses and hits her. When asked how long this has been going on, R52 stated since she (R52) has been in the facility for 3+ years. R52 stated that R15 slapped her in the face previously, but has not caused her bodily injury. R52 further stated that R15 has accused her (R52) of stealing R15's money and buying clothes. R52 stated that she was not the only person R15 abuses and stated when R15 walks down the hall, she'll use her walker to hit anyone in her way. R52 stated that if she see's R15 in the hall where they reside, she'll go into her room, close the door and turn down the television sound so she (R15) won't know I'm there. R52 stated that staff have observed these behaviors from R15 and advised her not to hit R15 back, however, she stated, I'd really like to hit her back. When asked if she's talked to staff about her concerns regarding R15, R52 stated that she talked to E1 (NHA) a few days ago and was told that they'd try to remove sitting chairs in the hall so if R15 sits, it will be in the area by the nurses station. E52 became tearful several times when discussing R15 and stated I don't even look in her (R15's) room when I walk by and the CNA's are afraid of her. When asked how all this makes her feel, R52 stated, I can't take it anymore. I feel terrible, it upsets me. Sometimes I feel like pulling my hair out by it's roots. R52 also stated that she didn't want to have a nervous breakdown . I don't want to have . one because of her (R15). R52 denied any further incidents with R15 throughout the survey from 11/28/18- 12/6/18. Record review revealed that R52 has received counseling from a psychologist (E15) on an ongoing basis since at least (MONTH) (YEAR). On 11/28/18 at 11:43 AM, R52 was seen by E15. R52's mood was described as depressed and anxious. The progress notes stated, . Pt (patient) discussed how she had an altercation with another resident and how the situation is being handled . Psychologist provided supportive and empathetic listening and feedback to pt(patient) . A progress note, dated 11/28/18 and timed 4:32 PM, was written by E2 (DON). The note stated, . Spoke with resident after interaction on 11/25/18. Resident states she feels much better today and that she slept 'like a baby' last night. Resident states she has felt comfortable on the unit and continues to sit and converse with peers . AAO x 3 (alert and oriented to person, place and time). Verbally able to make needs known. Continues to attend the dinning (sic) room for meals with good appetite . right arm . no marks or bruises . denies pain . Continues to self propel w/c (wheel chair) on and off unit without difficulty . Continues to participate in activities. A progress note, dated 11/28/18 and timed 5:51 PM, written by E2, stated, Spoke to resident daughter regarding resident status. Daughter pleased to hear resident doing well. Will continue to monitor. The 5 day follow up, written by E2 (DON), was submitted to the state agency on 11/30/18 for the 11/25/18 incident. The follow up stated, . Spoke with (R52) on 11/26 and 11/28 following interaction on 11/25. (R52) remains AAOx 3. Verbally able to make needs known . Seen by psychologist with no further interventions necessary. Resident (R15) with no further episodes of physical aggression towards other residents. Has dx (diagnosis) depression, pseudobulbar affect (neurological condition characterized with uncontrollable laughing and crying) and dementia. Has known behaviors related to physical aggression and receives counseling. Continues to ambulate (walk) on unit with RW (rolling walker) . ADON spoke with resident regarding programing on the dementia unit and potential benefits. Family in agreement to trail (sic- trial) unit during day before making a decision. R52 stated that R15 had not bothered her during the survey period of 11/28/18 through 12/6/18. On 12/5/18 at 2:35 PM, findings were discussed with E2 (DON) and she was advised that this was a harm level deficiency. The facility failed protect R52 from emotional, verbal and physical abuse from R15. R15 has a history of physical aggression towards staff and other residents, verbal aggression including yelling and cursing at staff and other residents, and false beliefs/accusations, including that someone stole her money and other belongings. R52, who is cognitively intact, stated that R15 curses at her, says hurtful things to her, and hits her, even going out of her way to do so, at times. R52 was most recently hit by R15 on 11/25/18. As a result of R15's behaviors towards R52, R52 stated that she secludes herself in her room when she see's R15 in the hall (both reside in same hall) by shutting her bedroom door and turning down the volume on her tv so R15 won't know R52's in her room. R52 also reported that she feels sad, upset and afraid due to R15's abuse. R52 stated that she doesn't want to have a nervous breakdown because of R15. 2. Review of R31's clinical record revealed the following: R31 was admitted to the facility in 2014. Review of a quarterly MDS assessment, dated 9/13/18, coded R31 on a scale of 0-15, with 0 being never/rarely made decisions and 15 being the highest level of cognition (decisions consistent/reasonable), as a 15. R31 was interviewed by the state surveyor on 11/28/18 at 9:58 AM. R31 stated that R15 wandered into his room last night about 2:00 AM and she was asking where someone was. R31 further stated, I feel like she doesn't belong on this floor, but family doesn't want her to go to 3rd floor. R31 further stated this was not the first time R15 had done this, but it's the first time in awhile. R31 stated that his roommate likes the door open, so R15 see's it open and wanders in. Findings were reviewed with E2 (DON) on 12/5/18 at 2:35 PM and advised this has the potential for harm. The facility failed to ensure R31 was free from potential abuse when R15 wandered into R31's room due to lack of adequate monitoring and supervision on 11/28/18 at approximately 2:00 AM. R15 has a history of distressed behaviors, including verbal and physical abuse of staff and other residents. R31 stated that R15 had wandered into his room previously, too. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E14 (RN/QA) on 12/6/18 at approximately 7:45 PM during the exit conference.

Based on record reviews, interviews, review of facility documentation and hospital records, it was determined that the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for two (R85 and R99) out of 54 sampled residents. For R85, the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice. The facility failed to have lab (laboratory) results available for physician review and failed to ensure that the physician was notified of abnormal lab results per facility policy. The facility failed to ensure that an H&H ordered to be drawn on 9/21/18 was completed. Additionally, the facility failed to identify that on 9/27/18, R85's episode of chest pain and shortness of breath could be related to low Hgb and failed to notify the physician when R85 exhibited these symptoms. This resulted in harm to R85 when she had to be emergently sent to the ER and subsequently hospitalized requiring emergency transfusion of 2 Units of PRBCs. For R99, the facility failed to ensure that the physician was notified when R99 refused [MEDICATION NAME] doses resulting in lost opportunities for the physician to adjust medication if he/she desired. The facility failed to notify the physician in a timely manner when R99 experienced a significant change in mental status and was deemed unsafe swallowing medications. Findings include: The facility policy titled, Laboratory and Radiologic Services, dated (MONTH) (YEAR), stated, Abnormal labs and x-rays are called to the charge nurse, who in turn, will notify the physician of the results. Physician notification will be documented in the electronic medical record. The facility policy titled, Physician-Notification of Abnormal Test Results, effective (MONTH) (YEAR), stated, .2. Results of laboratory .tests shall be reported in writing to the resident's attending physician from the testing source. 3. Abnormal results will be called and/or faxed to the physician upon receipt. Normal and abnormal test results provided to the facility will not be filed in the resident's chart before the physician reviews and signs the printed results. The results can be placed in a doctor's box for review and signature. The attending physician will initial and date the results when reviewed .5. The Unit Manager/Charge Nurse/Nurse Supervisor receiving abnormal results shall be responsible for notifying the physician of such test results .The nurse will enter date and time, and sign the report as reported to the physician. 6. Signed and dated reports of all diagnostic tests shall be made a part of the resident's electronic medical record. The facility policy titled, Provider Notification of Resident Change in Medical Condition, effective (MONTH) (YEAR), stated, .staff communicates changes in a resident's medical condition to providers in a timely and accurate manner .Changes in Resident Condition Staff will notify the provider .of: .Significant change in condition in physical, mental, or psychosocial status (i.e., deterioration in mental health, mental, or psychosocial status in either life threatening or clinical components) . 1. Review of R85's clinical record revealed: 8/7/16 - R85 was admitted to the facility with [DIAGNOSES REDACTED]. 7/14/17 - R85 was prescribed the medication Xarelto 20 mg daily, used to prevent blood clots in individuals with [MEDICAL CONDITION]. 8/28/17 - R85's care plan was updated and stated that she had the potential for bleeding due to anticoagulation therapy. Interventions included to monitor lab work as ordered, and to assess for signs of abnormal bleeding. 1/29/18 - A lab report revealed R85's hemoglobin (Hgb) was 12.6 (Normal range: 11.8-14.8). 8/17/18 - There was a physician's orders [REDACTED]. There was no documentation in the EMR signifying whether R85 was having any signs or symptoms of bleeding. 8/19/18 - On the day shift, the TAR documented R85 had a guaiac positive stool. 8/20/18 - On the evening shift, the TAR documented R85 had a guaiac positive stool. 8/20/18 - The lab results for the H&H revealed R85's Hgb was 10.5. This was a decrease of 2.1 points when compared to the 1/29/18 result of 12.6. 8/21/18 at 4:25 PM- A physician's progress note stated R85 was seen for [MEDICAL CONDITION] with 2 out of 3 positive stool guaiac tests. The physician noted that R85 had weight loss, never had a colonoscopy, and had a first relative with a [DIAGNOSES REDACTED]. The plan was to consult a GI physician for EGD and colonoscopy, repeat a CBC, check iron study, vitamin B12, and folic acid in 1 week. 8/21/18 - Review of the EMR revealed that R85 was scheduled for a GI consult on 10/1/18 at 2:00 PM for [MEDICAL CONDITION] with positive guaiac stools and a family history of [MEDICAL CONDITION]. 8/22/18 at 3:42 PM - A nurse's progress note stated that R85 had a third guaiac positive stool, and that the physician would review on the next rounds. R85's clinical record lacked evidence that the physician reviewed her chart following this finding. 8/29/18 - The TAR revealed a signature signifying that R85 had a CBC, iron study, vitamin B12 level and folic acid drawn. Review of the EMR revealed there were no results scanned into the record for these blood tests. Upon surveyor request on 12/4/18, the facility provided the blood test results after obtaining them via fax from the lab. Results of R85's Hgb revealed the level was 9.8, a further decrease from the 10/5/18 Hgb result of 10.5 and the iron level was 24 (normal range 35-165). There was no documented evidence stating that the physician was notified of the results, nor was there any evidence showing that the physician had reviewed the results (no physician dated and initialed copy). 9/13/18 - A physician's orders [REDACTED]. 9/15/18 - Lab results revealed R85's Hgb was 7.9, again signifying a decrease from 8/29/18 when it was 9.8. There was no documentation that the physician was notified of this abnormal result per facility policy. 9/17/18 at 12:18 PM - A physician's progress note stated that R85's labs were reviewed and acknowledged that the Hgb was 7.9. The note stated that R85 was asymptomatic (no symptoms), had a prior history of gastritis, and had no abdominal pain or dark/tarry stools. The note stated the plan was to guaiac stools, check CBC and monitor for any GI bleeding. 9/17/18 - A physician's orders [REDACTED]. 9/19/18 - The CBC result revealed R85's Hgb was 7.4, down from 7.9 on 9/17/18. 9/19/18 11:15 PM - A nurse's progress note stated R85's Hgb level was 7.4 and that the NP was notified. The note stated a new order was received to check an H&H on Friday (9/21/18) and that the order was input. 9/21/18 - Review of the TAR revealed it was initialed by nursing staff signifying that the H&H was completed. Review of the Lab Form revealed that nursing staff had written in that R85 was due for an H&H and that it was signed off and dated as completed by the lab technician on 9/21/18. There were no results found for the 9/21/18 H&H. The was no evidence that the facility followed up with the lab to determine why there were no results sent to the facility. 9/22/18 - During the day shift, the TAR documented R85 had a guaiac positive stool. There was no documented evidence that the physician was notified. 9/25/18 - During the day shift, the TAR documented R85 had a guaiac positive stool. There was no documented evidence that the physician was notified. 9/27/18 2:10 PM - A nurse's progress note stated that during lunch time R85 complained of shortness of breath and chest pain. The note stated sublingual [MEDICATION NAME] was administered along with a nebulizer (medicated breathing treatment) and after 5 minutes the resident stated she felt better. There was no evidence that the nursing staff considered these symptoms could be related to R85's low Hgb and there was no evidence that the episode of chest pain and shortness of breath was reported to the physician. 9/28/18 2:27 PM - A nurse's progress note stated that while out at a cardiology appointment, the facility was notified that R85 had a large bloody bowel movement and was being sent to the ER for further evaluation. Review of hospital records revealed that on arrival to the ER, R85's Hgb was 6.7. R85 required transfusion of 2 units of PRBC, was admitted to the hospital and was found during a colonoscopy to have multiple polyps. 12/4/18 at 1:00 PM - During an interview, E2 (DON) stated that the process was for the facility to receive lab results via fax. The evening shift supervisor reviews the lab results and ensures that the physician is notified of any abnormalities. E2 stated it would have been the responsibility of the evening supervisor to inquire about the missing H&H results on 9/21/18. 12/6/18 approximately 8:10 AM - An interview was conducted with E1 (NHA), E2, E3 (ADON) and E4 (Medical Director). E4 stated that the current standard of practice was to transfuse when the Hgb was below 7 and the patient was symptomatic. E4 stated that previously the standard was to transfuse when the Hgb was below 8. E4 stated the facility was monitoring for symptoms and/or if R85's blood pressure dropped the resident would have been sent out to the ER. It was discussed with E4 that the facility failed to identify that results from the 9/21/18 H&H were never received and that the Hgb level might have decreased further. E4 nodded her head. The facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for R85. The facility failed to document what precipitated R85's 8/17/18 H&H and stool guaiac orders, and failed to have lab results available for physician review. The facility failed to ensure that the physician was notified of abnormal lab results per facility policy, failed to document that the physician was notified of an abnormal lab result per facility policy, and failed to provide evidence that an H&H ordered for R85 on 9/21/18 was completed. Additionally, the facility failed to identify that on 9/27/18, R85's episode of chest pain and shortness of breath might be related to the low Hgb and failed to notify the physician when R85 exhibited these symptoms. This resulted in harm to R85 when she had to be emergently sent to the ER and subsequently hospitalized requiring emergency transfusion of 2 Units of PRBCs. Findings were reviewed with E2 (DON) on 12/4/18 at 1:00 PM. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 2. Review of R99's EMR revealed the following: 5/17/18 - R99 was readmitted to the facility post hospitalization with [DIAGNOSES REDACTED]. 6/16/18 - A quarterly MDS assessment stated R99 was alert and able to make decisions independently. 9/5/18 - A physician's orders [REDACTED]. 9/7/18 - The ammonia level results revealed a value of 93 (normal range: 0-60). 9/7/18 - A physician's orders [REDACTED]. The order further stated to administer [MEDICATION NAME] 45 mls three times a day and [MEDICATION NAME] 30 mls once daily (a total of 4 doses per day) x 3 days and to obtain an ammonia level on 9/14/18. 9/8/18 through 9/10/18 - Review of the MAR indicated [REDACTED] - 9/8/18 - all four doses of [MEDICATION NAME] were administered; - 9/9/18 - two doses of [MEDICATION NAME] were refused by R99 and two doses were administered; - 9/10/18 - one dose of [MEDICATION NAME] not administered due to refusal and one dose documented R99 was LOA (Leave of Absence). Review of the EMR lacked evidence that the facility attempted to administer the missed dose when R99 returned from the LOA. Additionally, there was no documented evidence that the facility notified the physician when R99 refused doses. 9/11/18 - Review of the EMR revealed that the previous orders for [MEDICATION NAME] were resumed (30 mls 3 times a day and 45 mls once a day). 9/11/18 through 9/14/18 - Review of the MAR indicated [REDACTED] - 9/11/18 - all four doses administered; - 9/12/18 - all four doses administered; - 9/13/18 - one dose of [MEDICATION NAME] refused and no evidence of physician notification; - 9/14/18 - all doses administered. 9/14/18 - Review of laboratory results revealed that the ammonia level, ordered on [DATE], was not drawn. Review of the 24 Hour Report for 9/8/18 lacked evidence that a 24 hour chart check was completed. 9/14/18 3:59 pm - A nurse's progress note stated the resident was due for an ammonia level, but the draw was not completed because the test was not ordered. The progress note stated the lab was called and rescheduled the ammonia level for 9/15/18. 9/15/18 - Review of the Lab Form revealed that although an ammonia level was entered for R99, it was not signed off by the lab technician as completed. A notation stated Must be called in for Monday 9/17/18. 9/15/18 - Review of the MAR indicated [REDACTED]. There was no evidence the facility attempted to administer the [MEDICATION NAME] upon R99's return from LOA and there was no evidence of physician notification. 9/16/18 - A quarterly MDS assessment stated R99 was alert and able to make decisions independently. 9/16/18 - Review of the MAR indicated [REDACTED]. 9/17/18 - Review of the MAR indicated [REDACTED]. 9/17/18 - An ammonia level was drawn (ordered to be drawn on 9/14/18) with a value of 133. 9/17/18 8:36 pm - A nurse's progress note stated R99's ammonia level was 133, the physician was notified, there were no new orders, and that the physician would review when in the facility. 9/18/18 - Review of the MAR indicated [REDACTED]. 9/19/18 - Review of physician's orders [REDACTED]. However, [MEDICATION NAME] orders were then changed back to the prior doses. Further review revealed that the consultant pharmacist completed a medication review to determine if R99's medications were causing an increase in the ammonia level. There were no irregularities found by the pharmacist. 9/19/18 - Review of the MAR indicated [REDACTED]. The 7 PM dose was not administered and documented in the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Despite this change in R99's mental status, the facility failed to notify the physician. 9/19/18 3 PM to 11 PM shift - Review revealed there were no nurse's progress notes despite the fact that R99 was too lethargic to be given oral medications. 9/20/18 - The MAR indicated [REDACTED]. 9/20/18 3:23 AM - A nurse's progress note stated to send the resident to the emergency room for further evaluation and management. 9/20/18 3:39 AM - A nurse's progress note stated, Resident noted for increase (sic) lethargy .(Nurse Practitioner) made aware at 3:00am with new order to send resident to hospital for further evaluation and management .Call placed to 911. Transferred to the hospital at 3:30am. Review of the Resident CNA Documentation Record from 9/1/18 through 9/19/18 revealed a total of 10 days on which R99 had no bowel movements. Although R99 was administered a [MEDICATION NAME] suppository on 9/19/18 at 3:25 PM, there was no evidence that it was effective. Review of progress notes lacked evidence of the physician having been notified of R99's lack of bowel movements as was desired with the administration of [MEDICATION NAME]. 12/3/18 12:00 PM - During an interview, E2 (DON) provided a 24 Hour Report which staff are to pull/print to verify and check accuracy of any new orders written in the preceding 24 hours (24 hour chart check). The 24 Hour Report revealed that on 9/8/18, staff failed pull the report to complete the 24 hour chart check. Had the 24 hour chart check been completed it would have identified that the ammonia level ordered on [DATE] to be completed on 9/14/18 was not entered for a lab draw. 12/3/18 3:35 PM - In an interview, E10 (RN) confirmed she was assigned to R99 on 9/19/18 on the day shift. E10 stated that she recalled the resident was quieter and more drowsy than usual. E10 also stated she recalls R99 attended a care plan meeting that day. 12/3/18 5:05 PM - During an interview, E11 (RN) confirmed he was R99's assigned nurse on 9/19/18 on the evening shift. E11 stated that it was evident (R99) was declining. E11 stated the resident had been having intermittent confusion and lethargy over the past several weeks. E11 stated R99 was lethargic but arousable, but he did not feel it was a good idea to give anything by mouth. E11 stated he did not feel there was a need to notify the physician and that vital signs (blood pressure, pulse, respirations, temperature) were within normal range. 12/5/18 9:24 AM - In an interview, E12 confirmed she was R99's assigned nurse on 9/20/18 on the night shift. E12 stated that working night shift most residents are asleep and at times it is difficult to determine if there is a change in mental status. E12 stated she started her rounds at approximately 10:45 PM and R99 was asleep. At 12 AM, E12 stated she went in to administer an [MEDICATION NAME] dose and found R99 lethargic, which was not the residents' usual baseline. E12 stated she had been told in change of shift report that R99's ammonia level was elevated and that the resident was lethargic. E12 stated she held the 12 AM [MEDICATION NAME] dose because she felt it was not safe to give it due to the lethargy. E12 stated she went in again around 3 AM and woke R99, who opened her eyes and then promptly closed them. E12 stated this was not R99's norm, as she would usually smile at her. E12 stated she then called the physician and the resident was sent to the hospital. 12/5/18 approximately 8:10 AM - An interview was conducted with E1 (NHA), E2 (DON), E3 (ADON), and E4 (Medical Director). E4 stated that it is difficult to increase a resident's medication ([MEDICATION NAME]) if they are refusing doses. E4 stated that if resident was refusing doses she would not necessarily have increased the dose. E4 was informed that there was no evidence that the physician was notified about the medication refusals, that ordered labs were not completed timely and that when a change in mental status occurred there was a delay in informing the physician, E4 nodded her head. The facility failed to ensure that the physician was notified when R99 refused [MEDICATION NAME] doses resulting in lost opportunities for the physician to adjust medication if he/she desired. The facility failed to notify the physician in a timely manner when R99 experienced a significant change in mental status and was deemed unsafe swallowing medications. At least an 8 hour delay occurred before the physician was notified and R99 was sent to the emergency room for evaluation. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA).

Based on observation, record review and interview, it was determined that the facility failed to ensure that one resident (R6), with a limited ROM, out of 28 Stage 2 sampled residents, received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. The facility failed to identify and assess R6's limitation in ROM of the left hand on admission and failed to develop and implement an individualized ROM program that included the affected left extremity. Findings include: On 6/1/15 at 12:00 PM, during Stage 1 of the survey, R6 was observed seated in a w/c in his room with the 3rd, 4th and 5th fingers of the left hand in a closed position against the palm and scratching the left side of head with 1st finger which he was able to extend. No movement was observed of the last 3 fingers of his left hand. During a staff interview during Stage 1 with E10 (LPN) on 6/1/15 at 1:49 PM, E10 stated R6 had a contracture to his left hand and did not receive any ROM exercises and did not wear a splint. R6 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/6/14 Admission Nursing Assessment under ROM Limitations did not identify any issues and was left blank, and also stated there was no limitation of the left upper extremity and that R6 was able to move it. The 8/7/14 Medical History and Physical (H&P) identified R6 as having full ROM of the upper extremities. The 8/8/14 OT Evaluation and Plan of Treatment did not identify any limitations of R6's left hand. The 8/8/14 PT Evaluation and Plan of Treatment did not identify any limitations of R6's left hand. On 8/11/14 the therapy department completed an annual ROM Assessment. Although this form did not include ROM measurements of the hands and fingers, it stated the resident presents with no limitations. According to the 8/13/14 admission MDS assessment, R6's vision was severely impaired, the BIMS indicated his daily decision making skills were intact, and he required extensive assist of one staff person for bed mobility, transfers, dressing, eating, toilet use and hygiene. This same MDS stated that R6 had no functional impairments in ROM of the upper extremities. Physician's recertification visits, dated 8/15/14 and 9/3/14, did not note any issues with ROM. The DE Monthly FCS, review period 9/4/14 to 10/1/14, stated R6 had no contractures. This review failed to identify and document R6's left hand ROM limitations. On 9/30/14 a physician's orders [REDACTED]. This contracture management program failed to include exercises to R6's hands and fingers. Review of physician's orders [REDACTED]. On 10/1/14 the facility developed a care plan for the problem Resident is at risk of developing contractures and/or limitation in motion secondary to [DIAGNOSES REDACTED]. The goal was ROM or contractures will improve or experience/exhibit no worsening, observable or measurable, by next review in 90 days. Interventions included: Active assist range of motion exercises to bilateral shoulders, elbows, knees and ankles BID x 15 minutes daily (again did not include R6's hands); assess response to ROM exercises at least monthly, noting observable changes status quo; consult with therapist, PT/OT, as necessary . A physician's recertification visit, dated 10/1/14, did not note any issues with ROM. The DE Monthly FCS, review period 10/2/14 to 10/29/14, stated R6 had no contractures. A quarterly MDS assessment, dated 11/5/14, stated R6 had no functional impairment in ROM of the upper extremities. A physician's recertification visit, dated 11/6/14, noted full ROM and weakness of both upper extremities. R6's left hand ROM limitation was not noted. The DE Monthly FCS, review period 10/30/14 to 11/26/14, 11/27/14 to 12/24/14, and 12/25/14 to 1/21/15, stated R6 had no contractures. Review of the EMR revealed R6 was hospitalized from [DATE] through 12/30/14. R6 was re-admitted to the facility on [DATE]. The 12/30/14 Admission Nursing Assessment noted R6 had no ROM limitations of the upper extremities and again failed to identify and assess R6's left hand limitation in ROM. A physician's recertification visit, dated 1/9/15, did not note any issues with ROM of the upper extremities and/or left hand. The DE Monthly FCS, review period 1/22/15 to 2/18/15, stated R6 had no contractures. A physician's recertification visit, dated 1/29/15, stated R6 had full ROM. A quarterly MDS assessment, dated 2/4/15, stated R6 had no functional impairment in ROM of the upper extremities. The DE Monthly FCS, review period 2/19/15 to 3/18/15 and 3/19/15 to 4/16/15, stated R6 had no contractures. A physician's recertification visit, dated 3/20/15, stated R6 had full ROM and did not note any issues with ROM of the upper extremities and/or left hand. Review of the EMR revealed R6 was hospitalized from [DATE] through 4/6/15. The 4/6/15 Admission Nursing Assessment stated under the section Physical Status that yes there was ROM Limitations of the left upper extremity. However, there was no description of what the limitation was under the comment section. Additionally this assessment also noted there was no musculoskeletal limitation of the upper extremity and that R6 was able to move the left upper extremity. On 4/13/15, a rehabilitation screening was completed to determine if there was a need for therapy services. This screen stated R6 appeared to be at baseline and there were no current therapy needs. Physician recertification visits, dated 4/16/15 and 4/30/15, did not note any limited ROM of the left upper extremity. The DE Monthly FCS, review period 4/17/15 to 5/14/15, stated R6 had no contractures. A quarterly MDS assessment, dated 5/6/15, stated R6 had no functional impairment in ROM of the upper extremities. Review of the EMR revealed R6 was hospitalized from [DATE] through 5/21/15. The 5/22/15 Admission Nursing Assessment stated there were no ROM limitations of the left upper extremity. On 5/22/15, a rehabilitation screening was completed to determine if there was a need for therapy services post hospitalization . This screen stated R6 was at baseline and there were no current therapy needs. A physician's orders [REDACTED]. Review of ADL Flow Sheets from 10/1/14 through 5/31/15 revealed CNAs were signing off completion of AAROM twice a day for 15 minutes to both shoulders, elbows, knees and ankles, except for times of hospitalization . There was no evidence of any ROM being provided to R6's wrists and hands. The following observations and/or interviews were conducted: 6/4/15 at 11:20 AM - R6 was observed seated in w/c in his room, holding a large foil snack bag between the left thumb and 1st finger and did not show any effort to move the other three fingers. After completing the snack R6 was observed scratching the left side of his head with his extended left first finger, the last three fingers remained closed against his palm. R6 was asked if he was able to open all the fingers of his left hand? He stated No, cause of arthritis. 6/5/15 at 8:00 AM - lying on bed, left hand last 3 fingers pressed down against palm. 6/5/15 at 10:40 AM - during interview with E8 (CNA), she stated that she has taken care of R6 since she started in the facility in February, 2015. E8 stated she completes ROM exercises to his arms and legs during morning care and tries to open up his left hand during care to check the skin and to look that nails are clipped and not digging into the palm. E8 also stated that R6's left hand has been like this since she started caring for him. She stated that she is only able to open it slightly, maybe a 1/4 of the way, and then R6 will say that its starting to hurt a bit. 6/5/15 approximately 3:00 PM - observed R6's left hand with E6 (Rehab Director); E6 stated she was not able to locate any documentation in therapy notes of any ROM limitations of R6's left hand. E6 stated that one PT did say that he believes R6 had something with the hand but nothing was documented as the resident was able to utilize a rolling walker. E6 stated currently R6 was able to open the left thumb and index fingers, however there was a limitation of the 3rd, 4th and 5th fingers. 6/5/15 at 4:25 PM - during an interview with E1 (NHA), E2 (DON) and E6 findings were reviewed. E1 stated that R6 has not had a decline in function, as he is able to feed himself with use of adaptive equipment. It was pointed out by the surveyor that R6 is right handed and uses that hand for holding eating utensils, and that he only uses the left thumb and 1st finger when holding anything in his left hand. A Rehab Screening Form, dated 6/5/15, stated .seen today for L hand ROM assessment .found to have full extension of L thumb and index finger and limited extension of 3rd, 4th, and 5th digits. Spoke with nursing who reports pt function remains the same despite limited finger extension .Feel no splinting device is warranted at this time. Feel splinting device may inhibit pt functional use of hand as well as potential of splint to create pressure area. Will add ROM to L hand on contracture management program at this time. This is the first time the left hand was added to the contracture management program in over a 3 month period after it was established. A progress note, dated 6/6/15 and timed 4:37 PM, stated Therapy completed a screen related to L hand ROM assessment. Resident was found to have full extension of L thumb and index finger and limited extension of 3rd, 4th and 5th digits .Call placed to POA to discuss findings of the Therapy Screen .stated that she (POA) is aware and that resident has experienced this issue for '2 years or longer', . In a surveyor interview on 6/11/15 at 9:10 AM with F1 (R6's family member), she stated she usually visits once a week. When asked about the resident's left hand, F1 stated When he was in his apartment (prior to admission to facility), it was like that, it was starting. Now it's worse, he cannot open it and use it like he used to. During an interview on 6/11/15 at 10:07 AM with E6 and E7 (PT), who treated R6 when first admitted , E6 stated that everyone admitted gets an initial ROM assessment completed and that going forward there will be a change to add hands as part of the assessment. E7 stated she worked with R6 when he was first admitted and again in March. E7 also stated that there was a limitation of the left hand when he first came in, but it was not documented. E7 stated that, as a PT, she would look at gross motor function, transfer ability and if they can function with what they have. E7 stated the resident gets agitated when you try to work with his hand. E7 also said, I didn't address his hands because the feeling was it has been there a long time, so he works around it. We assumed that it was his baseline for that hand. He had a limitation before he got here according to his daughter. E6 stated with his behaviors, we do not want to cause pain, not best practice. We will look at changing our form. As a PT, I would make note of the hand, lesson learned. I will be more diligent about my documentation. Review of supplemental documentation submitted by the facility on 6/17/15 stated that R6 was able to grasp the handle of a standard rolling walker which measures 4 & 9/16th inches. This same document stated the facility implemented a formal ROM program to the digits on 6/5/15. After implementation of the ROM program to the digits the PT assessment dated [DATE] measures the hand grasp of a hollow dowel at 5 & 3/4th inches. This demonstrates an increase in ROM after a ROM program was instituted. The facility failed to accurately assess R6 on admission and on multiple occasions by multiple disciplines. The facility failed to identify the need to implement a contracture management program for the left hand (prior to 6/5/15). There is no evidence the facility completed monthly monitoring for a decline in ROM (as there was no documentation of any limitation of the left hand to begin with) as per the care plan and no evidence of any services provided in an attempt to increase ROM and/or prevent further decrease. Although interviews confirmed that R6 entered the facility with some degree of limitation in ROM of his left hand, there is no documentation as to the extent of the limitation and a family member confirmed that, Now it's worse, he cannot open it and use it like he used to. The facility failed to provide treatment and services to increase ROM or to prevent further decrease in ROM. Findings were discussed with E1, NHA and E2 on 6/11/15 at approximately 3:00 PM.

Based on clinical record reviews, review of facility documents and staff interviews it was determined that the facility failed to ensure that one resident (R4) out of nine sampled residents was adequately supervised to prevent a fall that resulted in a fracture requiring transfer to an acute care facility. Findings include: Review of the clinical record revealed R4 had [DIAGNOSES REDACTED]. Review of the quarterly MDS (minimum data set) assessment dated [DATE] and the MDS completed for a significant change in status and dated 5/26/2013 revealed that R4 had short-term and long-term memory problems and exhibited moderately impaired decision making skills. The MDS dated [DATE] and the MDS dated [DATE] also revealed that R4 was totally dependent on the physical assistance of one person for locomotion on and off the unit and required extensive assistance of two plus persons for physical assistance of transfers. According to the above two referenced MDS assessments R4 is currently on a toileting plan to manage her urinary incontinence (involuntary excretion of urine). Further review of the clinical record revealed R4 scored 16, a high risk for falls, on three fall risk assessments completed by the facility on 10/15/2012, 1/14/2013 and 4/9/2013 and prior to a fall with injury on 5/8/2013. The current care plan originated 5/9/2011 revealed development of the focus area "(R4) has a high predictive factor for falls as she has exhibited a decline in function and mental status R/T (related to) advanced dementia. She lacks safety awareness and exhibits impulsive behaviors of standing without assist...". The above referenced care plan also included the goal "(R4) will not experience any preventable falls or injury (for) 90 days". Among the interventions originating on 5/1/2012 and included in this same care plan was "...Rehab to screen post fall and as indicated...". (The care plans lack specific intervals as to when they were reviewed, but they do include dates when interventions were implemented.) A "Therapy Timeline" submitted in writing by E12 (physical therapist) revealed that physical therapy recommended the usage of a wheelchair for R4's safety at all times due to changes in ambulation evaluated between 10/4/2012 and 10/9/2012. Further review of this "Therapy Timeline" revealed that R4's physician attributed changes in her alertness, ambulation and inability to tolerate therapy to "age related dementia changes." Between 11/20/2012 and 12/20/2012 the "Therapy Timeline" revealed that R4 expressed "inconsistent alertness and fluctuating mobility and transfer status." Another focus area originally initiated on the 10/25/12 care plan stated "(R4) presents safety hazard (as evidenced by) getting up from wheelchair to walk or transfer without calling for assistance" and with the goal that "(R4) understand the risks involved with safety hazard and/or to call for assistance". Description of the intervention developed to address the above referenced focus area included "Position (R4) where she can be seen and assist as needed". Additionally the "Therapy Timeline" revealed that R4 was assessed on 3/26/2013 by E13 (speech therapist) and obtained results of a decline from 4.0 to 3.0 on the Allen Cognitive Scale (an examination to determine someone's level of awareness or intellect). It is unclear how the facility evaluated the effectiveness of their interventions in the presence of the above mentioned physician and therapy evaluations of R4's decline in cognition and mobility. According to the facility incident report dated 5/8/2013 with attached "5 Day Follow-Up" and completed investigation R4 was found lying on her left side on the dining room floor at 11:40 AM on 5/8/2013. Prior to the fall R4 was seated in her wheelchair alone at a dining table awaiting the noon meal which was scheduled to begin at 12:00 PM. R4 was described as "calm and listening to the music playing". Review of a statement completed by E6 (certified nursing assistant), dated 5/8/2013 and timed 11:40 AM and attached to the incident report revealed that E6 (certified nursing assistant) was "watching" R4 as the resident sat in the dining room. However E6 (certified nursing assistant) "left R4 (unattended) to go get the tablecloths" and returned to the dining room to find R4 on the floor. Review of a nurse's note dated 5/8/2013 and timed 12:41 PM stated "...(R4) found lying on the floor in dining room on her left side behind her wheelchair...stated she was walking out to leave and then she fell ....stated that she slipped on the floor...When performing active and passive assist to left lower extremity...(R4) verbalizes pain...administered pain medication...physician...aware of fall and pain left hip...order given for x-ray of left hip...''. The same nurse's note dated 5/8/2013 and timed 12:41 PM revealed the dining room floor was clean and dry when R4 was transferred from the floor into her wheelchair with the physical assistance of two staff members following her fall. Another nurse's note recorded 5/8/2013 at 10:25 PM stated "...x-ray...done with positive result of acute left femoral neck (head of the thigh bone) fracture...order...send (R4) to an acute care facility for evaluation. In an interview conducted with E6 (certified nursing assistant) on 7/29/2013 at approximately 10:45 AM she stated that she was the sole staff member setting up tables in the dining room on the third floor for the noon meal. Although E6 (certified nursing assistant) stated that she turned her back instead of having left the dining room to gather tablecloths, she confirmed that she did not visualize R4 until she turned around looking into the dining room and observed R4 on the floor and her wheelchair positioned at an angle to the dining table. Further review of the above referenced attached statement revealed that in response to the question "Do you know of anything that may have contributed to the incident?", E6 (certified nursing assistant) replied in writing "Left unsupervised...". Additionally E6 (certified nursing assistant) stated that R4 was toileted prior to placement in the dining room and was dry after her fall. E6 (certified nursing assistant) also denied that the floor was wet after R4 fell . Review of another attached statement dated 5/8/2013 and timed 11:40 AM of the incident revealed the response to the question "What would you do to prevent this from happening again?" stated "(R4) needs to be supervised at all times?" Although the facility developed interventions to provide monitoring and supervision of R4's lack of safety awareness, it failed to provide supervision to prevent a fall with injury sustained by R4 that required care and treatment at an acute care facility. These findings were reviewed with E1 (administrator) and E2 (director of nursing) on 7/30/2013.

Based on record review, observation and interview, it was determined that the facility failed to ensure that one (1) resident (R89) out of 37 sampled, who entered the facility without pressure sores did not develop a pressure sore unless the individual's clinical condition demonstrates that they were unavoidable. According to R89's Minimum Data Set (MDS) assessments dated 3/03/11, 4/14/11 and 7/13/11, R89 was at risk for pressure ulcers but had no unhealed pressure ulcer at Stage 1 or higher. However on 8/09/11, R89 was discovered with an unstageable pressure ulcer on her left heel. Findings include: R89 had [DIAGNOSES REDACTED]. R89 had a history of [REDACTED]. On 9/29/09 this wound became unstageable and healed on 3/10/10. The wound reoccurred and presented as Stage 2 on 6/17/10 which healed on 7/6/10. On 11/3/10, R89 was readmitted to the facility from the hospital with a [DIAGNOSES REDACTED]. According to R89's MDS dated [DATE] this resident's cognitive skills for daily decision-making were moderately impaired. R89 required extensive to total assistance for most of her ADLs (Activities of Daily Living). R89 required assistance of two staff for bed mobility, transfers (with stand up lift) and toileting, and assist of one staff for bathing and dressing. She was dependent for wheelchair mobility and had no impairment in range of motion (ROM) of her upper and lower extremities. R89's Pressure Ulcer Risk Assessments, dated 4/25/11 and 7/18/11 indicated that she was at high risk for developing pressure sores. Review of the 7/13/11 MDS assessment revealed that R89 had no unhealed pressure ulcers Stage 1 or higher during this assessment period. The facility initiated a care plan, dated 5/27/08 and last revised on 3/11/11, entitled "Resident is High Risk for pressure ulcer/skin breakdown secondary to impaired mobility and urinary/fecal incontinence. She has DX (diagnosis) of [MEDICAL CONDITION] with delayed healing. She is dependent on staff for repositioning. She has exhibited a fluctuating nutritional intake". This care plan's interventions were: a. See TAR (Treatment administration record) for preventative measures of heels b. Monitor skin q (every) 2 hrs for s/sx(signs and symptoms) of potential breakdown (redness/discoloration, or open area), alert charge nurse if observed for notification of physician as needed to obtain treatment orders c. Anti-pressure mattress, and cushion for chair d. Provide a minimum of 12-16 oz of fluids per tray and encourage resident to consume e. Assist to turn and reposition q 2 hrs f. Keep skin clean and dry and bed linens clean/dry and wrinkle free as possible. g. Incontinence care after each episode h. Do not position directly onto trochanter when side-lying position used, maintain head of bed at lowest possible degree of elevation i. Apply barrier cream per MD j. Nutritional supplement as ordered A nurse's note dated 8/9/11 and timed 0650 (6:50 AM) stated, "skin prep tx (treatment) to (L) heel as ordered completed. Noted a raised thick area of hard skin with black tissue. Surrounding skin red (blanchable), dry and intact. No drainage or odor noted. Raised thick area of hard skin measures approximately 2.1cm x 1.8 cm x 0cm. Bilateral heels offloaded on pillows while in bed. Allevyn foam applied on L (left) heel for protection. MD and unit manager notified. R89's July/2011, August/2011's TAR for the facility's "Preventative measures for Heels" as per the care plan included "FYI (for your information) Off load Heels while in bed" and Elevate Legs while out of bed as she allows". Each block (represents days of the month) on the TAR had no single documented staff signature indicating that R89's heels were consistently offloaded. Review of nurse's notes for this same time period failed to indicate consistent offloading of the resident's heel and failed to note any refusals of the offloading by the resident. Additionally, the CNAs (Certified Nursing Assistant) Care sheets for the months of July/2011 and August/2011 also included instructions such as "Skin checks q 2 hrs and to report changes in skin to nurse". Although each dated daily block on all three shifts were signed off by the CNAs (indicating skin checks were completed every 2 hours on all three shifts), they failed to recognize and failed to identify signs and symptoms of an early stage of a developing pressure sore on the left heel prior to the discovery of her unstageable left heel pressure sore on 8/9/11. Additionally, the facility had a weekly "Skin Assessment/Body Checks" record form and assigned the 3-11 PM Nursing Staff to assess the resident's skin once a week (done every Tuesday). Staff nurse's signed off that the assessments were done on 7/5/11, 7/12/11, 7/19/11. 7/26/11, 08/2/11 and R89 refused on 8/9/11. There was no documentation of skin problems in nurses' notes and/or preventative measures/treatments initiated including a 24 hr Wound alert sheet. The 3-11 PM nursing staff failed to recognize/identify signs and symptoms of an early stage of a developing pressure sore on this resident's left heel. A Physician's history and physical examination 1-2 + [MEDICAL CONDITION] Left Lower tib (tibia) w/ 3 mm scabbed area. LE (Lower Extremities)- [MEDICAL CONDITION] slightly improved. scabbed area healing, skin-intact." However, it did not identify conditions of the left heel. Subsequently, a Weekly Wound Assessment, dated 8/10/11 stated findings of a left heel pressure wound unstageable 1.6 x 3 x UTD(unable to be determined), firmly adherent, brown no odor , no exudate edges defined which was first observed on 8/9/11. It further stated, "BLE (bilateral lower extremities) show 2+[MEDICAL CONDITION], cool to touch and chronic red toned in color. Unable to palpate pedal pulse. Feet are dry and flaky, thickened tissue noted." The facility's interventions noted on the Weekly Wound Assessment included the following:: Vitamins/Minerals Turning/Positioning schedule: q 2 hrs & PRN Support Surface; Standard pressure reduction mattress Cushions/pads/heel protectors: Incontinence management/toileting program: Incontinence care provided q 2 hrs and prn Skin Protection/N/A Current treatment: skin prep q shift, covered by non-adhesive foam dressing for protection, Off load heels while in bed, continue no shoe Under Hospice Benefit 8/17/11- Wound Assessment indicated some additional documented information, that is, resident has chronic issues to L heel; it is the site of a previously heeled ulceration on 7/6/10 and an area of thickened tissues noted on 11/3/10 and healed crevase like area on 5/4/11 same measurement as of 8/10/11. 9/1/11 - Wound Assessment; 9/8/11, 9/15/11, 9/23/11, 9/30/11, 10/7/11 measurement 1.6 x 2.8 x UTD no changes to treatment and rationale 10/18/11 - Wound Assessment: measurement: 2 x 2.8 x UTD, fibrotic/calloused/firm treatment - same interventions; Support surface: concave air mattress The MDS assessment, dated 10/05/11 indicated that this resident had a pressure ulcer Stage 1 or greater i.e.1 unstageable ulcer with suspected deep tissue injury in evolution. The facility failed to evaluate/identify R89's left heel pressure ulcer, failed to consistently monitor/implement interventions consistent with resident's needs and failed to revise the interventions as appropriate in a timely manner. This finding was discussed with E1 (Administrator) and E2 (Director of Nursing) on 10/24/11.